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 (___) PETITION FOR TEMPORARY CUSTODY OF MINOR CHILD(REN) BY EXTENDED FAMILY (___) PETITION FOR EMERGENCY TEMPORARY CUSTODY OF MINOR CHILD(REN) BY EXTENDED FAMILY 1. This Petition is being filed by (indicate your name and relationship to child{ren}), pursuant to Chapter 751, Florida Statutes. 2. The name(s), birth date(s) and current address(es) of the minor child(ren) is/are: NAME BIRTH DATE ADDRESS , 3. The name(s) and current address(es) of the parent(s) of the minor child(ren) is/are: NAME ADDRESS 4. The name(s) and current address(es) of the person(s) the child(ren) has/have lived with during the past five (5) years is/are: NAME CURRENT ADDRESS Law 1037 / Rev. 5-13-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com PAGE 2 CASE NO.: 05 - - DR - - XXXX-XX 5. Petitioner(s) live(s) at the following address: City State Zip Street Address Petitioner(s) receive(s) mail at the following address: Street Address City State Zip 6. List places where the child(ren) has/have lived during the past five (5) years: Dates Living at this Address From From From From From To To To To To Child(ren)'s Address 7. I (___) have not (___)have participated as a party, witness or in some capacity in any litigation or custody proceeding, in this or some other state, concerning custody of a child involved in these proceedings as follows: Name of each child: Type of proceeding: Court and State: Date of Court Order: 8. I (___)have no information (___)have the following information concerning a custody proceeding pending in a court of this or another state concerning a child involved in this proceeding as set out below: Name of each child: Type of proceeding: Court and State: Date of Court Order: Case Number: 9. I (___)do not know of any person (___)know that the following named person(s) not a party to this proceeding has physical custody or claims to have custody or visitation rights with respect to any child involved in this proceeding: Name of each child: Name of person claiming custody/visitation rights: Address of person claiming custody/visitation rights: Street Address (___)Has physical custody City State Zip (___)Claims custody rights (___)Claims visitation rights Law 1037 / Rev. 5-13-2013 American LegalNet, Inc. www.FormsWorkFlow.com PAGE 3 CASE NO.: 05 - - DR - - XXXX-XX 10. Petitioner(s)'s relationship to the child(ren) is/are: PETITIONER'S NAME: RELATIONSHIP TO CHILD(REN): If Petitioner is the putative father, indicate the circumstances leading Petitioner to believe he is the natural father of the child(ren). Putative father is defined as a man who reasonably believes himself to be the biological father of the minor child(ren), but who is unable to prove paternity due to the absence of the mother of the child(ren). 11. The circumstances of the child(ren)'s current living situation with Petitioner(s) and/or the reason(s)or this request for temporary custody is/are: 12. One or both of the parent(s) of the child(ren) have or have not given consent to this Petition in writing. If parent(s) has/have given consent, attach the original notarized consent(s). A. Mother (___)has (___)has not given consent. B. Father (___)has (___)has not given consent. 13. One or both of the legal parents has not given consent because: (NOTE: UNLESS CONSENTS ARE GIVEN, CHILD ABUSE, NEGLECT OR ABANDONMENT MUST BE STATED AND PROOF MUST BE PROVIDED TO THE COURT.) Law 1037 / Rev. 5-13-2013 American LegalNet, Inc. www.FormsWorkFlow.com PAGE 4 CASE NO.: 05 - - DR - - XXXX-XX 14. The child(ren) (___)is/are (___)is/are not in need of immediate medical treatment. If child(ren) are in need of immediate treatment, state the nature of the medical treatment required: 15. Please state the period of time Petitioner(s) is/are requesting temporary custody: 16. 17. (___) The Petitioner(s) is/are fit, able and willing to care for the minor child(ren). (___) Placement of the child(ren) with Petitioner(s) is in the best interest of the minor child(ren) because: 18. (___) This is an emergency because: (State how or why the child(ren) is/are in IMMEDIATE DANGER OR HARM) Law 1037 / Rev. 5-13-2013 American LegalNet, Inc. www.FormsWorkFlow.com PAGE 5 CASE NO.: 05 - - DR - - XXXX-XX WHEREFORE, Petitioner(s) respectfully request(s) that process may issue and that this Court grant the following relief: (___) The Petition be granted. (___) A hearing on the merits to be set. (___) Petitioner be authorized to obtain necessary medical treatment for the child(ren). (___) Petitioner be authorized to secure copies of the child(ren)'s records held by third parties. (___) Petitioner be authorized to enroll the child(ren) in school. (___) Any and all other relief deemed appropriate and in the best interest of the minor child(ren). I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this petition and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Petitioner Printed Name: Address: City, State, Zip: Telephone Number: STATE OF FLORIDA COUNTY OF BREVARD Sworn to (or affirmed) and subscribed before me this by . day of , 20 , Signature of Notary Public-State of Florida Check one only: ___Personally known ___Produced I.D. Print, type or stamp Commissioned Name Type of I.D. 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} {state} , {phone} , helped {name} who [ one only] _____petitioner or _____ respondent, fill out this form. , {city} , , , Law 1037 / Rev. 5-13-2013 American LegalNet, Inc. www.FormsWorkFlow.com