IN THE CIRCUIT COURT OF THE _________________________ JUDICIAL CIRCUIT IN AND FOR __________________________ COUNTY, FLORIDA Case No: ______________________ Division: ______________________ __________________________________, Petitioner, and __________________________________, Respondent/Father __________________________________, Respondent/Mother. ORDER GRANTING PETITION FOR CONCURRENT CUSTODY BY EXTENDED FAMILY This case came before this Court for a hearing on a Petition for Concurrent Custody by Extended Family. The Court, having reviewed the file and heard the testimony, makes these findings of fact and reaches these conclusions of law: SECTION I. FINDINGS: 1. The Court has jurisdiction over the subject matter and the parties. 2. The minor child(ren) at issue in this matter are: Name Date of Birth ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3. The Petitioner, {full legal name} _____________________________________ is the {extended family relationship}___________________________________________ of the child(ren). 4. The Petitioner currently has physical custody of the child(ren) and has had physical custody of the child(ren) for at least 10 days in any 30-day period within the last 12 months. Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com 5. The Petitioner does not have signed, written documentation from the parent(s) which is sufficient to enable the custodian to do all the things necessary to care for the child(ren) which are available to custodians who have an order for temporary custody by extended family. 6. The Mother {full legal name} _________________________________ of the child(ren): (choose one only) ___ Filed a Waiver and Consent ___ Was served with the petition and failed to file an Answer ___ Is deceased as evidenced by: _______________________________________ 7. The Father {full legal name} _________________________________ of the child(ren): (choose one only) ___ Filed a Waiver and Consent ___ Was served with the petition and failed to file an Answer ___ Is deceased as evidenced by: _______________________________________ 8. It is in the best interest of the child(ren) for the Petitioner to have concurrent custody. SECTION II: CONCURRENT CUSTODY 1. The Petitioner,___________________________________________________, is granted concurrent custody of the minor child(ren). 2. The Petitioner shall have all the concurrent rights and responsibilities of a legal parent. 3. The Petitioner is authorized to make all reasonable and necessary decisions for the minor child(ren), including but not limited to: a) Consent to all necessary and reasonable medical and dental care for the child(ren), including nonemergency surgery and psychiatric care; b) Secure copies of the child(ren)’s records, held by third parties, that are necessary for the care of the child(ren), including, but not limited to: i. Medical, Dental, and psychiatric records; ii. Birth certificates and other records; and iii. Educational records. 4. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be tested or placed in special school programs, including exceptional education; and 5. Do all other things necessary for the care of the child(ren). Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com SECTION III. CHILD SUPPORT 1. The Petitioner ____ did ____ did not request the establishment of child support. 2. ___ If child support is requested, the parents have received personal or substituted service of process, the petition requests an order for support of the child(ren), and there is evidence of the parents’ ability to pay the support ordered. The ( ) Mother ( ) Father has the present ability to pay child support (Choose one only) ___ The amounts in the Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e) filed by the ( ) Mother ( ) Father are correct; OR ___ The Court makes the following findings: The Mother’s net monthly income is $_______________, (Child Support Guidelines ___%). The Father’s net monthly income is $____________________, (Child Support Guidelines ____%) Monthly child care costs are $_________________. Monthly health/dental insurance costs are $_____________. OR ___ The ( ) Mother ( ) Father is currently ordered to pay child support to the other parent in the amount of $_____________ per ________________ as established in the case of (style of case and number} _________________________________________ _____________________________________________________________________. ( ) All of the child support or ( ) a portion of the child support in the amount of $_________ shall be redirected to the Petitioner. 3. Amount a) Father’s Obligation The Father shall be obligated to pay child support in the amount of $__________ for the _______children {total number of parties’ minor or dependent children} commencing _________________ {month, day, year} and terminating ________________________ {month, day, year}. Upon the termination of child support for one of the parties’ children, child support in the amount of $_____________ for the remaining _________ children {total number of remaining children} shall be paid commencing __________________ {month, day, year} and terminating _________________________ {month, day, year}. {Insert paragraph for the child support obligation, including the amount, commencement, and termination dates, for the remaining minor or dependent children, which shall be payable as the obligation for each child ceases.} The Father shall pay child support until all of the minor or dependent children: reach the age of 18, become emancipated, marry, join the armed services, die, or become selfFlorida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com supporting; or until further order of the court or agreement of the parties. The child support obligation shall continue beyond the age of 18 and until high school graduation for any child who is dependent in fact, between the ages of 18 and 19, and is still in high school, performing in good faith with a reasonable expectation of graduation before the age of 19. If the child support ordered deviates from the guidelines more than 5%, the factual findings which support that deviation are: ____________________________________ _______________________________________________________________________ _______________________________________________________________________. Child support shall be payable ( ) at least once a month and in accordance with the Father’s employer’s payroll cycle, or ( ) other {explain}___________________________ ________________________________________________________________________ b) Mother’s Obligation The Mother shall be obligated to pay child support in the amount of $____________ for the ________children {total number of parties’ minor or dependent children} commencing {month, day, year} and terminating __________________ {month, day, year}. Upon the termination of the obligation of child support for one of the parties’ children, child support in the amount of $__________ for the remaining ______ children {total number of remaining children} shall be paid commencing _____________________ {month, day, year} and terminating ________________________ month, day, year}. {Insert paragraph for the child support obligation, including the amount, commencement, and termination dates, for the remaining minor or dependent children, which shall be payable as the obligation for each child ceases.} The Mother shall pay child support until all of the minor or dependent children: reach the age of 18; become emancipated, marry, join the armed services, die, or become selfsupporting; or until further order of the court or agreement of the parties. The child support obligation shall continue beyond the age of 18 and until high school graduation for any child who is dependent in fact, between the ages of 18 and 19, and is still in high school, performing in good faith with a reasonable expectation of graduation before the age of 19. If the child support ordered deviates from the guidelines more than 5%, the factual findings which support that deviation are:______________________________________ ________________________________________________________________________ _______________________________________________________________________. Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com Child support shall be payable ( ) at least once a month and in accordance with the Mother’s employer’s payroll cycle, or ( ) other {explain}__________________________ _______________________________________________________________________. 4. Arrearages/Retroactive Child Support a) The ( ) Mother ( ) Father owes child support arrearages in the amount of $_________ as of {date} ________________ to the other parent. The child support arrearages shall be repaid in the amount of $_______ per month, payable ( ) in accordance with the employer’s payroll cycle, and in any event at least once per month ( )other {explain} ________________________________ __________________________________________________________________ commencing {date} ______________________, until paid in full including statutory interest. b) The ( ) Mother ( ) Father owes retroactive child support in the amount of $_________ as of {date} ________________ to the Petitioner. The retroactive child support shall be repaid in the amount of $_______ per month, payable ( ) in accordance with the employer’s payroll cycle, and in any event at least once per month ( )other {explain} __________________________________________ __________________________________________________________________ commencing {date} ______________________, until paid in full including statutory interest. 5. Insurance (Choose all that apply) a) ( ) Mother ( ) Father shall be required to maintain ( ) health and/or ( ) dental insurance for the parties’ minor child(ren), so long as reasonable in cost and accessible to the child(ren). The party providing insurance shall be required to convey insurance cards demonstrating said coverage to the Petitioner and other parent. OR ( ) health and/or ( ) dental insurance is either not reasonable in cost or accessible to the child(ren) at this time. b) ___ Reasonable and necessary uninsured medical/dental/prescription drug costs for the minor child(ren) shall be assessed as follows: ( ) Shared equally by both parents. ( ) Prorated according to the child support guidelines percentages. ( ) Other {explain} ______________________________________________ As to these uninsured medical/dental/prescription drug expenses, the party who incurs the expense shall submit a request for reimbursement to the parent or Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com parents within 30 days, and the parent or parents, within 30 days of receipt, shall submit the applicable reimbursement for that expense. SECTION IV. METHOD OF PAYMENT The parent(s) shall pay court-ordered child support and arrearages, if any, as follows: 1. Place of Payment a) ___Parents shall pay court-ordered support directly to either the State Disbursement Unit or the central depository, as required by statute, along with any applicable fee required by statute. OR b) ___ The Petitioner and the Parents have requested and the court finds that it is in the best interest of the child(ren) that support payments need not be directed through either the State Disbursement Unit or the central depository at this time; however, any party may subsequently apply, pursuant to section 61.13(1)(d)(3), Florida Statutes, to require payment through either the State Disbursement Unit or the central depository. 2. Income Deduction (If applies) a) ___ Immediate. ( ) Mother ( ) Father, hereinafter, Obligor(s), shall pay through income deduction, pursuant to a separate Income Deduction Order which shall be effective immediately. Obligor is individually responsible for paying this support obligation until all of said support is deducted from his/her income. Until support payments are deducted, the Obligor is responsible for making timely payments directly to the State Disbursement Unit or the Petitioner as previously set forth in this Order. b) ___ Deferred. Income deduction is ordered this day, but it shall not be effective until a delinquency of $_____________, or, if not specified, an amount equal to one month’s obligation occurs. Income deduction is not being implemented immediately based on the following findings: Income deduction is not in the best interests of the child(ren) because: {explain} _________________________ _______________________________________________________________ _______________________________________________________________. AND There is proof of timely payment of a previously ordered obligation without an Income Deduction Order, AND ( ) there is an agreement by the Obligor(s) to advise the State Disbursement Unit of any change in Payor and/or health insurance OR ( ) there is a signed, Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com written agreement providing an alternative arrangement between the Petitioner and Obligor(s). 3. Bonus/one-time payments. [Choose one only] ( ) All ( ) __________% ( ) No income paid in the form of a bonus or other similar onetime payment, up to the amount of any arrearage or the remaining balance thereof owed pursuant to this order, shall be forwarded to the Petitioner pursuant to the payment method prescribed above. 4. Other provisions relating to method of payment: _______________________________ ________________________________________________________________________ SECTION V. ATTORNEY FEES, COSTS, AND SUIT MONEY (Choose one only) 1. ___ ( ) Petitioner’s ( ) Respondents’ request(s) for attorney fees, costs, and suit money is (are) denied because ____________________________________________________ _____________________________________________________________________. 2. ___ The Court finds there is a need for and ability to pay attorney fees, costs, and suit money. ( ) Petitioner ( ) Respondent(s) is (are) ordered to pay the other party $________ in attorney fees, and $ ______ in costs. The Court further finds that the attorney fees are awarded based on the reasonable rate of $________________ per hour and ________________ reasonable hours. Other provisions relating to attorney fees, costs, and suit money are as follows: _____________________________________ _______________________________________________________________________. SECTION VI. OTHER PROVISIONS 1. Other Provisions _________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. The Court reserves jurisdiction to modify and enforce this Order for Concurrent Custody. 3. The granting of concurrent custody does not affect the ability of the child(ren)’s parent or parents to obtain physical custody of the child(ren) at any time. Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com DONE AND ORDERED in _____________________, Florida on {date} ____________________ _____________________________ CIRCUIT JUDGE A copy of this Order for Concurrent Custody was: [Choose one only] ( ) mailed ( ) faxed and mailed ( ) hand delivered to the parties listed below on {date}___________ by____________________________. {Clerk of court or designee} Petitioner (or his or her attorney) Respondents (or his or her attorney) State Disbursement Unit or Central Depository Other _________________________________ Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by Extended Family (03/12) American LegalNet, Inc. www.FormsWorkFlow.com