IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA CASE NO.:05 IN THE INTEREST OF: Clock In / Minor Child(ren) - DR - - XXXX-XX (___)ORDER UPON PETITION FOR TEMPORARY PARENTAL RESPONSIBILITY OF MINOR CHILD(REN) BY EXTENDED FAMILY (___) ORDER UPON PETITION FOR EMERGENCY TEMPORARY PARENTAL RESPONSIBILITY OF MINOR CHILD(REN) BY EXTENDED FAMILY THIS CAUSE came to be heard on {date} _____________________________, 20____, before this Court, upon the (___) Petition for Temporary Parental Responsibility of Minor Child(ren) By Extended Family or (___)Petition for Emergency Temporary Parental Responsibility pursuant to Chapter 751, Florida Statutes and the Court having reviewed the file and being fully advised in the premises finds as follows: 1. Petitioner is the of the minor child(ren) and has physical parental responsibility of the minor child(ren) to wit: CHILD(REN)'S NAME(S) DATE OF BIRTH 2. 3. 4. This Court has jurisdiction over the above-referenced child(ren). The Mother of the child(ren) is The Mother (___) has (___) has not consented in writing to the entry of this Order for Temporary Parental Responsibility. Law 1040 ­ Rev. 05-20-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com Case No.: 05 Page 2 - DR - - XXXX-XX 5. The Mother is unwilling or unable to consent in writing for the following reasons: 6. The Father of the child(ren) is 7. The Father (___) has (___)has not consented in writing to the entry of this Order for Temporary Parental Responsibility 8. The Father is unwilling or unable to consent in writing for the following reasons: 9. (___) Petitioner(s) is/are fit, able and willing to care for the minor child(ren). 10. (___) Placement of the child(ren) with Petitioner(s) is in the best interest of the minor child(ren). 11. (___) Parental Responsibility is requested as a result of abuse, neglect and/or abandonment of the child(ren) by the (___)Mother and/or by the (___)Father 12. (___) This is an emergency because: . THEREFORE, IT IS HEREBY ORDERED AND ADJUDGED: 1. (___) That the Petition for Temporary Parental Responsibility of the Minor Child(ren) By Extended Family is HEREBY GRANTED. 2. (___) That the Petition for Emergency Temporary Parental Responsibility of Minor Child(ren) is HEREBY GRANTED. Law 1040 ­ Rev. 05-20-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com Case No.: 05 Page 3 - DR - - XXXX-XX 3. (___) That the Petitioner, ____________________________________, shall have physical and legal parental responsibility until further order of the Court of the minor child(ren) to wit: CHILD(REN)'S NAME(S) DATE OF BIRTH 4. (___) Petitioner is HEREBY AUTHORIZED to obtain necessary medical treatment for the child(ren). 5. (___) Petitioner is HEREBY AUTHORIZED to secure copies of the child(ren)'s records held records, held by third parties, that are necessary for the care of the child(ren) including but not limited to: A. Medical, dental and psychiatric records; B. Birth certificates and other records; and, C. Educational records. 6. (___) Petitioner is HEREBY AUTHORIZED to enroll the child(ren) in school and grant or withhold consent for a child to be tested to placed in special school programs, including exceptional education. 7. (___) Petitioner is HEREBY AUTHORIZED to do all other things necessary for the care of the minor child(ren). 8. ( ) CHILD SUPPORT: The child support shall be redirected as follows: The Respondent {name} address , shall promptly pay for support and maintenance of the minor child(ren), the sum of $ per plus Clerk's costs of 4% of said payment but not more than $5.25 payment and not less than $1.25 per payment, to the State of Florida Disbursement Unit, P.O. Box 8500, Tallahassee, Florida 32314-8500, commencing on , 20 , and continuing each thereafter, for disbursement to the Petitioner , address . Law 1040 ­ Rev. 05-20-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com Case No.: 05 Page 4 - DR - - XXXX-XX 9. CHILD SUPPORT ARREARAGE: Payments of previously ordered support not paid is $__________. Said payments are owed to {name} address , and shall be paid as follows: . 10. 11. This Court shall retain jurisdiction over this cause and the minor child(ren) to enter any and all orders deemed necessary to assure the safety and welfare of the minor child(ren). ORDERED on this day of , 20 . CIRCUIT JUDGE COPIES TO: Law 1040 ­ Rev. 05-20-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com