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IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT, IN AND FOR ST LUCIE COUNTY, FLORIDA

,

Petitioner,

and

Case No.: Division:

,

Respondent.

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT

I, {full legal name} .div1 , being sworn, certify that the following statements are true:

1. The number of minor child(ren) subject to this proceeding is . The name, place of birth, birth date, and sex of each child; the present address, periods of residence, and places where each child has lived within the past five (5) years; and the name, present address, and relationship to the child of each person with whom the child has lived during that time are:

   
   

   THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 1 :

   
   

   Child’s Full Legal Name: Place of Birth: Date of Birth: Sex:

   
   

   Child’s Residence for the past 5 years:

   
   

   Dates (From/To)	Address (including city and state) where child lived	Name and present address of person child lived with	Relationship to child
   /present*
   /
   /
   /
   /

   
   

   Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (12/10)

   
   

   /

   * If you are the petitioner in an injunction for protection against domestic violence case and you have filedaRequest for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), you should write confidential in any space on this form that would require you to enter the address where you are currently living.

   
   

   THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :

   
   

   Child’s Full Legal Name: Place of Birth: Date of Birth: Sex:

   Child’s Residence for the past 5 years:

   
   

   Dates (From/To)	Address (including city and state) where child lived	Name and present address of person child lived with	Relationship to child
   /present
   /
   /
   /
   /
   /

   
   

   THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :

   
   

   Child’s Full Legal Name: Place of Birth: Date of Birth: Sex:

   Child’s Residence for the past 5 years:

   
   

   Dates (From/To)	Address (including city and state) where child lived	Name and present address of person child lived with	Relationship to child
   /present
   /

   
   

   Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (12/10)

   /
   /
   /
   /

   
   

2. Participation in custody or time-sharing proceeding(s):

   [ Choose only one]

   

   I HAVE NOT participated as a party, witness, or in any capacity in any other litigation or custody proceeding in this or any other state, concerning custody of or time-sharing with a child subject to this proceeding.

   I HAVE participated as a party, witness, or in any capacity in any other litigation or custody proceeding in this or another state, concerning custody of or time-sharing with a child subject to this proceeding. Explain:

   1. Name of each child:

   2. Type of proceeding:

   3. Court and state:

   4. Date of court order or judgment (if any):

      
      

3. Information about custody or time-sharing proceeding(s):

   [Choose only one]

   I HAVE NO INFORMATION of any custody or time-sharing proceeding pending in a court of this or any other state concerning a child subject to this proceeding.

   I HAVE THE FOLLOWING INFORMATION concerning a custody or time-sharing proceeding pending in a court of this or another state concerning a child subject to this proceeding, other than set out in item 2. Explain:

   1. Name of each child:

   2. Type of proceeding:

   3. Court and state:

   4. Date of court order or judgment (if any):

      
      

4. Persons not a party to this proceeding:

   [Choose only one]

   I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or claims to have custody, visitation or time-sharing with respect to any child subject to this proceeding.

   I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has (have) physical custody or claim(s) to have custody, visitation, or time-sharing with respect to any child subject to this proceeding:

   1. Name and address of person:

      
      

      

      ( ) has physical custody ( ) claims custody rights ( ) claims visitation or time-sharing

      Name of each child:

      
      

      Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (12/10)

      
      

   2. Name and address of person:

      
      

      

      ( ) has physical custody ( ) claims custody rights ( ) claims visitation. or time-sharing

      Name of each child:

   3. Name and address of person:

      
      

      

      ( ) has physical custody ( ) claims custody rights ( ) claims visitation or time-sharing

      Name of each child:

      
      

5. Knowledge of prior child support proceedings:

   [Choose only one]

   The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this or any state or territory.

   The child(ren) described in this affidavit are subject to the following existing child support order(s):

   1. Name of each child:

   2. Type of proceeding:

   3. Court and address:

   4. Date of court order/judgment (if any):

   5. Amount of child support paid and by whom:

      
      

6. I acknowledge that I have a continuing duty to advise this Court of any custody, visitation or time-sharing, child support, or guardianship proceeding (including dissolution of marriage, separate maintenance, child neglect, or dependency) concerning the child(ren) in this state or any other state about which information is obtained during this proceeding.

I certify that a copy of this document was [Choose only one] ( ) mailed ( ) faxed and mailed ( ) hand delivered to the person(s) listed below on {date} .div1 .

Other party or his/her attorney:

Name: Address: City, State, Zip: Fax Number:

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (12/10)

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

Dated:

STATE OF FLORIDA

Signature of Party

Printed Name: Address: City, State, Zip: Telephone Number: Fax Number:

COUNTY OF

ST LUCIE

Sworn to or affirmed and signed before 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]

I, {full legal name and trade name of nonlawyer} .div1 , a nonlawyer, located at {street} .div1 , {city} .div1 ,

{state} .div1 , {phone} .div1 , helped {name} .div1 , who is the [Choose only one] petitioner or respondent, fill out this form.

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (12/10)