Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(11/15)INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.995(b), SUPERVISED/SAFETY-FOCUSED PARENTING PLAN (11/15) When should this form be used? A Parenting Plan is required in all cases involving minor child(ren). This form or a similar form should be
used in cases when you feel your child(ren) cannot be safely alone with the other parent or if you
believe shared parental responsibility presents a detriment to the child(ren). In this case, a Parenting
Plan must be developed that allows time-sharing with any minor child(ren), while providing protection
for the child(ren). If safety or supervised time-sharing is not a concern, Parenting Plan, Florida Supreme
Court Approved Family Law Form 12.995(a) or a similar form should be used. If the case involves
relocation, pursuant to Section 61.13001, Florida Statutes, then Relocation/Long Distance Parenting
Plan, Florida Supreme Court Approved Family Law Form 12.995(c) or a similar form should be used.
This form should be typed or printed in black ink. If an agreement has been reached, both parties must
sign the Parenting Plan and have their signatures witnessed by a notary public or deputy clerk. After
completing this form, you should file the original with the clerk of the circuit court in the county where
the petition was filed and keep a copy for your records. You should then refer to the instructions for
your petition, answer, or answer and counterpetition concerning the procedures for setting a hearing or
trial (final hearing). If the parents have not reached an agreement, a proposed Parenting Plan may be
filed by either parent at the time of or any time prior to the final hearing. If an agreed Parenting Plan is
not filed by the parties, the court shall establish a Plan.
IMPORTANT INFORMATION REGARDING E-FILING The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or other documents electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
The rules and procedures should be carefully read and followed. IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION After the initial service of process of the petition or supplemental petition by the Sheriff or certified
process server, the Florida Rules of Judicial Administration now require that all documents required or
permitted to be served on the other party must be served by electronic mail (e-mail) except in certain
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration. If you elect to participate in electronic service, which means serving or receiving pleadings
by electronic mail (e-mail), or through the Florida Courts E-Filing Portal, you must review Florida Rule of
Judicial Administration 2.516. You may find this rule at www.flcourts.org through the link to the Rules of
Judicial Administration provided under either Family Law Forms: Getting Started, or Rules of Court in the
A-Z Topical Index.SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail,
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(11/15)the procedures must always be followed once the initial election is made.To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address , Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears. Please
CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme Court
Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida Supreme
Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516. Where can I look for more information? Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. The words that are in “bold underline” in these instructions are defined
there. For further information, see chapter 61, Florida Statutes, and the instructions for the petition
and/or answer that were filed in this case.
Special notes... If you fear that disclosing your address would put you in danger, you should complete a Request for
Confidential Filing of Address, Florida Supreme Court Approved Form 12.980(h), file it with the clerk of
the circuit court and write confidential in the space provided in the Parenting Plan.At a minimum, the Parenting Plan must describe in adequate detail:How the parties will share and be responsible for the daily tasks associated with the upbringing
of the child(ren), The time-sharing schedule arrangements that specify the time that the minor child(ren) will
spend with each parent,A designation of who will be responsible for any and all forms of health care, school-related
matters, including the address to be used for school-boundary determination and registration,
other activities, and The methods and technologies that the parents will use to communicate with the child(ren).The best interests of the child(ren) is the primary consideration in the Parenting Plan. In creating the
Parenting Plan, all circumstances between the parents, including their historic relationship, domestic
violence, and other factors must be taken into consideration. Determination of the best interests of the
child(ren) shall be made by evaluating all of the factors affecting the welfare and interest of the
particular minor child(ren) and the circumstances of that family, as listed in section 61.13(3), Florida
Statutes, including, but not limited to: The demonstrated capacity and disposition of each parent to facilitate and encourage a close
and continuing parent-child relationship, to honor the time-sharing schedule, and to be
reasonable when changes are required; The anticipated division of parental responsibilities after the litigation, including the extent to
which parental responsibilities will be delegated to third parties; The demonstrated capacity and disposition of each parent to determine, consider, and act upon
the needs of the child(ren) as opposed to the needs or desires of the parent; The length of time the child(ren) has lived in a stable, satisfactory environment and the
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(11/15)desirability of maintaining continuity;The geographic viability of the parenting plan, with special attention paid to the needs of school-
age children and the amount of time to be spent traveling to effectuate the parenting plan. This
factor does not create a presumption for or against relocation of either parent with a child(ren); The moral fitness of the parents; The mental and physical health of the parents; The home, school, and community record of the child(ren); The reasonable preference of the child(ren), if the court deems the child(ren) to be of sufficient
intelligence, understanding, and experience to express a preference; The demonstrated knowledge, capacity, and disposition of each parent to be informed of the
circumstances of the minor child(ren), including, but not limited to, the child(ren)’s friends,
teachers, medical care providers, daily activities, and favorite things;The demonstrated capacity and disposition of each parent to provide a consistent routine for
the child(ren), such as discipline, and daily schedules for homework, meals, and bedtime; The demonstrated capacity of each parent to communicate with and keep the other parent
informed of issues and activities regarding the minor child(ren), and the willingness of each
parent to adopt a unified front on all major issues when dealing with the child(ren); Evidence of domestic violence, sexual violence, child abuse, child abandonment, or child
neglect, regardless of whether a prior or pending action relating to those issues has been
brought. If the court accepts evidence of prior or pending actions regarding domestic violence,
sexual violence, child abuse, child abandonment, or child neglect, the court must specifically
acknowledge, in writing that such evidence was considered when evaluating the bests interests
of the child(ren); Evidence that either parent has knowingly provided false information to the court regarding any
prior or pending action regarding domestic violence, sexual violence, child abuse, child
abandonment, or child neglect; The particular parenting tasks customarily performed by each parent and the division or
parental responsibilities before the institution of litigation and during the pending litigation,
including the extent to which parenting responsibilities were undertaken by third parties;The demonstrated capacity and disposition of each parent to participate and be involved in the
child(ren)’s school and extracurricular activities;The demonstrated capacity and disposition of each parent to maintain an environment for the
child(ren) which is free from substance abuse;The capacity and disposition of each parent to protect the child(ren) from the ongoing litigation
as demonstrated by not discussing the litigation with the child(ren), not sharing documents or
electronic media related to the litigation with the child(ren), and refraining from disparaging
comments about the other parent to the child)ren); and The developmental stages and needs of the child(ren) and the demonstrated capacity and
disposition of each parent to meet the child(ren)’s developmental needs.This standard form does n o t include every possible issue that may be relevant to the facts of your case.
The Parenting Plan should be as detailed as possible to address the time-sharing schedule. Additional
provisions should be added to address all of the relevant factors. The parties should give special
consideration to the age and needs of each child.In developing the Parenting Plan, you may wish to consult or review other materials which are available
at your local library, law library or through national and state family organizations.
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(11/15)Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15) IN THE CIRCUIT COURT OF THE ____________________ JUDICIAL CIRCUIT IN AND FOR ____________________ COUNTY, FLORIDA Case No: ____________________Division: _____________________________________________________Mother,and_________________________________Father. SUPERVISED/SAFETY-FOCUSED PARENTING PLAN This parenting plan is: {Choose only one} A Parenting Plan submitted to the court with the agreement of the parties. A proposed Parenting Plan submitted by or on behalf of:{Parent’s Name} . A Parenting Plan established by the court.This parenting plan is: {Choose only one} A final Parenting Plan established by the court. A temporary Parenting Plan established by the court. A modification of a prior final Parenting Plan or prior final order.I. PA REN TS MotherName: _________________________________________________________________________Address: _______________________________________________________________________Telephone Number: ______________________________________________________________E-Mail: _____________________________________________________________________________ Address Unknown: {Please indicate here if mother’s address is unknown}_____ Address Confidential: {Please indicate here if mother’s address and phone numbers a re
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence,
or _____ oth er c o u rt o rd er _______________________________________________________ }.FatherName: _________________________________________________________________________Address: _______________________________________________________________________Telephone Number: ______________________________________________________________E-Mail: _____________________________________________________________________________ Address Unknown: {Please indicate here if mother’s address is unknown}_____ Address Confidential: {Please indicate here if mother’s address and phone numbers a re
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence,
or _____ oth er c o u rt o rd er _______________________________________________________ }.II. CHILDREN: This parenting plan is for the following child(ren) born to, or adopted by the parties:(add additional lines as needed)
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15)Nam e Date of BirthIII. JURISDICTIONThe United States is the country of habitual residence of the child(ren).The State of Florida is the child(ren)’s home state for the purposes of the Uniform Child Custody
Jurisdiction and Enforcement Act.This Parenting Plan is a child custody determination for the purposes of the Uniform Child Custody
Jurisdiction and Enforcement Act, the International Child Abduction Remedies Act, 42 U.S.C.
Section 11601 et seq., the Parental Kidnapping Prevention Act, and the Convention on the Civil
Aspects of International Child Abduction enacted at the Hague on October 25, 1980, and for other
state and federal laws.Oth er: .IV.PARENTAL RESPONSIBILITY {Choose only one} Sole Parental ResponsibilityIt is in the best in te re sts of the ch ild (r e n ) that the Moth er Fa th er sh all have sole
authority to make major decisions for the child(ren.) It is detrimental to the child(ren) for the
parents to have shared parental responsibility.
Shared Parental Responsibility with Decision Making AuthorityIt is in the best interests of the child(ren) that the parents confer and attempt to agree on the
major decisions involving the child(ren). If the parents are unable to agree, the authority for
making major decisions regarding the child(ren) shall be as follows:Ed u ca tio n/A ca d em ic d ecis io ns _____ Moth er _____ Fa th erN on-e m erg e n cy h ealt h c a re _____ Moth er _____ Fa th er _ __ ____ _________________ ___ __ _ _____ Moth er _____ Fa th er_ __ ____ _________________ ___ ___ _____ Moth er _____ Fa th er_ __ ____ _________________ ___ __ _ _____ Moth er _____ Fa th er Other: (Explain) .V.TIME SHARING SCHEDULE {Choose only one}1. _____ No Time-Sharing: The _____ Mother _____ Father shall have no contact with the
child(ren) until further order of the court. All parenting decisions shall be made by the
other parent.2. _____ Supervised Time-Sharing: Whenever the child(ren) are with the _____ Mother
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15)_____ Fa th er, the su perv is o r s h all b e p re se n t. T h e Moth er Fa th er has the
right to spend time with the child(ren) even though the other parent will be making most,
if not all, of the parenting decisions which are made on the child(ren)’s behalf. The time-
sharing schedule shall be mutually agreed to between the parents, but not less than the
schedule set forth below: {Choose only one}
a. _____ hours per week. The place(s), and time(s) shall be set by the _____ Mother_____ Father.b. _____ Fro m _____ m. t o _____ m, on the f o llo w in g d ay(s ) ____________________ ______________________________________________________________________ 3. Restr ic te d T im e-S h arin g: T h e _____ Moth er _____ Fa th er s h all h ave time-sharing with
the following restrictions. {The restrictions should be described in detail such as time-
sharing only in public places, no overnight visits, etc.} The time-sharing schedule shall be
mutually agreed upon between the parents, but not less than the schedule set forth
below: _____________________________________________________________________ ____ _________________ ________________________ ___________________________ ____ _________________ ________________________ ___________________________ ____ _________________ ________________________ ___________________________ ____ _________________ ________________________ ________________________4. _____ hours per week. The place(s), and time(s) shall be set by the_____ Moth er _____ Fa th er.5. _____ O th er: ______ ____________________________ _____________________ _____.VI. SUPERVISOR AND SUPERVISION {Choose only one}1.Supervisor. The person supervising the time-sharing shall: {Choose only one}_____ Be s e le cte d b y the _____ Moth er _____ Fa th er._____ Be s e le cte d b y t h e _____ M oth er _____ Fa th er, s u b je ct to t h e o th er p are n t’s a p pro va l._____ Oth er: ______ _______ ________________________ __________________ _____ .2.Restrictions or Level of Supervision: _______________________________________________________________________________________________________________________________________________________________________________________3.Costs of Supervision_____T he c o sts o f t h e s u perv is io n s h all b e p aid b y t h e _____ Moth er _____ Fa th er_____ Oth er: ______ _______ ________________________ __________________ _____ .VII. LOCATION: {Choose only one}Th e _____ Moth er _____ F a th er s h all s p en d h is /h er t im e-s h arin g with the child (r e n ) at th e
following location(s):
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15)1._____ Supervised visitation center (name and address of facility) ______________________________________________________________________________________________2.__________________________________ (location ) or other location designated by t h e
_____ M oth er _____ Fa th er3. _____ A ny lo ca tio n d esig n ate d b y t h e _____ Moth er _____ Fa th er with the a p pro va l of th e
supervisor.4. _____ O th er: ______ ___ ________________________ ______________________ _____ .VIII. DESIGNATION FOR OTHER LEGAL PURPOSES1.The child(ren) named in this Safety-Focused Parenting Plan are scheduled to reside the majority
of the time with th e _____ Moth er _____ Fa th er. This majority designation is SOLELY for
purposes of all other state and federal statutes which require such a designation. This
designation does not affect either parent’s rights and responsibilities under this parenting
plan.2.For purposes of school boundary determination and registration, the _____ M oth er’s _____
Fa th er’s address shall be designated.IX. TRANSPORTATION AND EXCHANGE OF CHILD(REN)1. TransportationThe child(ren) shall not be driven in a car unless the driver has a valid driver’s license,
automobile insurance, seat belts, and child safety seats as required by Florida law.T h e _____ Moth er _____ Fa th er or mutu ally agre ed u po n p ers o n sh all b e re sp o nsib le fo r
transporting the child(ren) to the exchange point. The child(ren) shall be picked up and/or
returned to the exchange point by {Choose only one}a. _____ T h e _____ Moth er _____ Fa th er w it h the su p erv is o r p re se n t.b. _____ The supervisor alone.c._____ O th er: ______ ________________________ ______________________________ .2.ExchangeThe exchange of the child(ren) shall occur at: {Indicate all that apply}a. _____ The site of the supervised visit.b. _____ A monitored exchange location {specify name and address of facility} _________c. _______________________________________________________________________.d._____ Other: ____________________________________________________________.e. _____ The _____ Mother _____ Father is prohibited from coming to the exchange point.
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15)X. COMMUNICATION1.Between ParentsAll communications regarding the child(ren) shall be between the parents. The parents shall not
use the child(ren) as messengers to convey information, ask questions, or set up schedule
changes._____ The parents shall communicate with each other: {Indicate all that apply}_____ in person_____ by telephone_____ by letter_____ by e-mail_____ Other: {Specify} ___________________________________________________._____ No Communication. Unless otherwise prohibited by court order, all information and
communication regarding the child(ren) shall be exchanged via or through _______________________________________________________________________________________________________2.Between Parent and Child(ren)Th e _____ Moth er _____ F a th er { In dic a te a ll t h at a pply }a . _____ Shall not telephone, write, or e-mail the child(ren) unless the contact is agreed to
in advance by the other parent.b. _____ May write or e-mail the child(ren) at any time. Each parent shall provide a contact
address (and e-mail address if appropriate) to the other parent, unless other prohibited by court
order.c. _____ May call the child(ren) on the telephone _____ times per week. The call shall last
no more than _____ minutes and shall take place between _____ m. and _____ m. Each parent
shall provide a telephone number to the other parent, unless otherwise prohibited by court
order or law.d. _____ Long distance telephone calls made by the child(ren) to a parent shall be paid by
__________________. Each parent shall provide a telephone number to the other parent,
unless otherwise prohibited by court order or law.e. _____ Other: ____________________________________________________________.3.Costs of Electronic Communication“Electronic communication” includes telephones, electronic mail or e-mail, webcams, video-
conferencing equipment and software or other wired or wireless technologies or other means of
communication to supplement face-to face contact.The costs of electronic communication shall be addressed as follows:______________________________________________________________________________________________________________________________________________
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15)_______________________________________________________________________XI. ACCESS TO ACTIVITIES AND EVENTSTh e _____ Moth er _____ F a th er { C hoose o n ly o n e}1. _____ Shall not attend the child(ren)’s activities and events, including but not limited to, school,
athletic, and extra-curricular activities and events.2._____ May attend the child(ren)’s school, athletic, and extra-curricular activities and events.3._____ T h e _____ Moth er _____ Fa th er m ust s ta y _____ fe et f r o m the other pare n t a n d _____
feet from the child.4. _____ Other: ____________________________________________________________.XII. CHILD(REN)’S SAFETYTh e _____ Moth er _____ F a th er s h all f o llo w t h e s a fe ty r u le s c h eck e d b elo w .(Indicate all that apply )1._____ There shall be no firearms in the home, car, or in the child(ren)’s presence during time-
sharing.2._____ No alcoholic beverages shall be consumed from twenty-four (24) hours before the
child(ren) arrive until they are returned to the other parent.3._____ The child(ren) shall not be disciplined by corporal punishment.4._____ The following person(s) present a danger to the child(ren) and shall not be present during
time-sharing: _________________________________________________________________________________________________________________________________________________________5. _____ O th er: _ ________________________________ ___________________________.XIII. CHANGES OR MODIFICATIONS OF THE PARENTING PLANAll changes to the Safety-Focused Parenting Plan must be pursuant to a court order.XIV. OTHER PROVISIONS____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15) SIGNATURES OF PARENTS I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
Plan and intend to be bound by it.Dated: ______________________ _______________________________________ Signature of MotherPrinted Name: _____________________________Address: __________________________________City, State, Zip: _____________________________Telephone Number: _________________________Fax Number: ______________________________Designated E-mail Address(es): _________________________________________________________STATE OF FLORIDACOUNTY OF _________________________S w orn t o or a ffir m ed and sig n ed b efo re me on _____ by _ ______________________________________._______________________________________NOTARY PUBLIC or DEPUTY CLERK_______________________________________{Print, type, or stamp commissioned name of
notary or clerk.} _____ Personally known_____ Produced identification Type of identification produced _______________________
Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (11/15)I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
Plan and intend to be bound by it.Dated: ______________________ _______________________________________ Signature of FatherPrinted Name: _____________________________Address: __________________________________City, State, Zip: _____________________________Telephone Number: _________________________Fax Number: ______________________________Designated E-mail Address(es): _________________________________________________________STATE OF FLORIDACOUNTY OF _________________________S w orn t o or a ffir m ed and sig n ed b efo re me on _____ by _ ______________________________________._______________________________________NOTARY PUBLIC or DEPUTY CLERK_______________________________________{Print, type, or stamp commissioned name of
notary or clerk.} _____ Personally known_____ Produced identification Type of identification produced _______________________IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:[fill in all blanks] This form was prepared for the: {choose only one} ( ) Mother ( ) Father This form
was completed with the assistance of:{name of individual} ____________________________________________________________________,{name of business} ____________________________________________________________________,{a ddre ss} ____________________________________________________________________________,{ c it y } _ __ _______________, { s ta te } _____, {z ip c o d e} _ ____ _____, {t e le p hon e n um ber} _ _____________,