IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: Bar Code Label IN RE: TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION OF , Minor Child(ren) MOTION FOR SEARCH AND CERTIFICATE OF SEARCH PUTATIVE FATHER REGISTRY The Petitioner, ___________________________________, requests the Court enter an order, pursuant to Section 63.054, Florida Statutes, instructing the Bureau of Vital Statistics to search the Florida Putative Father Registry and issue a Certificate indicating a search has been completed. Section 63.0541, Florida Statutes, makes information maintained by the Registry confidential and exempt from public disclosure, except that is may be disclosed to adoption entities, registrant unmarried biological fathers, and the Court, upon issuance of a court order concerning a petitioner acting pro se. As grounds therefore Petitioner would state: 1. The Petitioner is the mother of the following minor child(ren): _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ 2. The Petitioner is requesting a termination of parental rights pending a stepparent adoption of said minor children. I certify that a copy of this document was [v one only] [ ] mailed [ ] faxed and mailed [ ] hand delivered to the person(s) listed below on {date} ________________________________, 20_____: Other party or his/her attorney: Name____________________________________ Address__________________________________ City, State, Zip____________________________ Telephone No.____________________________ Law 1078 - Rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com MOTION FOR SEARCH AND CERTIFICATE OF SEARCH PUTATIVE FATHER REGISTRY Page 2 Case No:________________________________ I understand that I am swearing or affirming under oath to the truthfulness of the claims made above and that the punishment for knowingly making a false statement includes fines and/or imprisonment. _______________________________________ Signature of Party ______________________________ Date Printed Name____________________________ Address_________________________________ City, State, Zip___________________________ Telephone Number________________________ Fax Number_____________________________ STATE OF FLORIDA COUNTY OF BREVARD Sworn to or affirmed and signed before me on ____________________________, 20____, By ________________________________________. _________________________________________ NOTARY PUBLIC or DEPUTY CLERK [Print, type or stamp commissioned name of notary or clerk] _____ Personally known _____ Produced identification Type of identification produced ____________________. I CERTIFY that I have ___ mailed, ___ telefaxed and mailed, or ___ hand delivered a copy of this motion on _____________________________, to: Name_________________________________ Address_______________________________ Telefax No.____________________________ 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 {Petitioner’s name} __________________, ____________________________________, who [v one only] _____petitioner or _____ respondent, fill out this form. Law 1078 - Rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com Law 1078 - Rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com