IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT, IN AND FOR BREVARD COUNTY, FLORIDA Case No.: , BAR CODE LABEL Petitioner, and , Respondent. AFFIDAVIT REGARDING JUVENILE DEPENDENCY I, ______________________________, hereby swear that to the best of my knowledge, the minor child(ren) subject to this proceeding is/are not the subject of a juvenile dependency action. Dated: Signature of Signing Party Printed Name: Address: City, State, Zip: Telephone Number: Fax Number: STATE OF FLORIDA COUNTY OF 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} , a nonlawyer, located at {street} {city} , {state} , {phone} , helped {name} , who is the respondent, fill out this form. Law 1100 Rev. 02/2007 American LegalNet, Inc. www.FormsWorkflow.com