Fill and Sign the Parenting Coordinator Florida Form

INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.984(b) RESPONSE BY PARENTING COORDINATOR (07/14) When should this form be used? A person appointed as a parenting coordinator must accept or decline the appointment under Florida Family Law Rule of Procedure 12.742(e). If you accept the appointment, you must complete paragraphs 1(a) and 2 and sign it. If you decline the appointment, you must complete only paragraph 1(b) and sign the form. This form should be typed or printed in black ink. Important Consideration Before Responding. A Qualifed Parenting Coordinator or other licensed mental health professional under Chapter 490 or 491, Florida Statutes, shall abide by the ethical and other professional standards imposed by his or her licensing authority, certifcation board, or both, as applicable. A person who is not a Qualifed Parenting Coordinator or a licensed mental health professional under Chapter 490 or 491, Florida Statutes, shall not accept an appointment to serve as parenting coordinator in a matter that presents an apparent or undisclosed confict of interest. A confict of interest arises when any relationship between the parenting coordinator and either party compromises or appears to compromise the parenting coordinator’s ability to serve. The burden of disclosure of any potential confict of interest rests on the parenting coordinator. Disclosure shall be made as soon as practical after the parenting coordinator becomes aware of the potential confict of interest. If a parenting coordinator makes an appropriate disclosure of a confict of interest or a potential confict of interest, he or she may serve if all parties agree. However, if a confict of interest substantially impairs a parenting coordinator's ability to serve, the parenting coordinator shall decline the appointment or withdraw regardless of the express agreement of the parties. A parenting coordinator shall not provide any services to either party that would impair the parenting coordinator's ability to be neutral. What should I do next? After completing and signing this form, you must fle the original with the clerk of the circuit court in the county in which the action is pending and keep a copy for your records. You must mail or hand-deliver a copy of this form to the attorney(s) for the parents or, if not represented by an attorney, to the parents. Instructions for Florida Family Law Rules of Procedure Form 12.984(b), Response by Parenting Coordinator (07/14) 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. For more information, see section 61.125; Florida Statutes, Florida Family Law Rule of Procedure 12.742, Rules for Qualifed and Court Appointed Parenting Coordinators and the Order of Referral to Parenting Coordinator , Florida Family Law Rules of Procedure Form 12.984(a). Special notes Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fll out these forms, that person must give you a copy of Disclosure from Nonlawyer , Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fll 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. Instructions for Florida Family Law Rules of Procedure Form 12.984(b), Response by Parenting Coordinator (07/14) IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT, IN AND FOR ______________________________ COUNTY, FLORIDA Case No: ________________________ Division: ________________________ _________________________________, Petitioner, and _________________________________, Respondent. RESPONSE BY PARENTING COORDINATOR I, {name} _________________________________________notify the Court and affirm the following: 1. Acceptance. [Choose only one ] a. ____ I accept the appointment as parenting coordinator. b. ____ I decline the appointment as parenting coordinator. 2. Qualifcations. [Choose only one ] a. ____ I meet the qualifcations in section 61.125(4), Florida Statutes. b. ____ I do not meet the qualifcations in section 61.125(4), Florida Statutes. However, the parties have chosen me by mutual consent and I believe I can perform the services of a parenting coordinator because: ____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. I am not aware of any confict, circumstance, or reason that renders me unable to serve as the parenting coordinator in this matter and I will immediately inform the court and the parties if such arises. 4. I understand my role, responsibility, and authority under the Order of Referral to Parenting Coordinator, Florida Family Law Rules of Procedure Form 12.984(a); section 61.125, Florida Statutes; Florida Family Law Rule of Procedure 12.742; and Rules for Qualifed and Court Appointed Parenting Coordinators. Florida Family Law Rules of Procedure Form 12.984(b), Response by Parenting Coordinator (07/14) I hereby afrm the truth of the statements in this acceptance and understand that if I make any false representations in this acceptance, I am subject to sanctions by the Court. _____________________ _____________________________________________ Date Signature of Parenting Coordinator Printed Name:_________________________________ Address: _____________________________________ City, State, Zip: ________________________________ Telephone Number: ____________________________ E-mail: _______________________________________ Professional License # (if applicable) _______________ Professional Certifcation # (if applicable) ____________ Copies to: _____Petitioner _____Attorney for Petitioner _____Respondent _____Attorney for Respondent _____Other: _______________________________ IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fll in all blanks] This form was completed with the assistance of: {name of individual} ___________________________________________________________________, {name of business} _____________________________________________________________________, {address} ____________________________________________________________________________, {city} ______________________, {state} __________, {tele phon e number} ________________________. Florida Family Law Rules of Procedure Form 12.984(b), Response by Parenting Coordinator (07/14)