IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT FOR BREVARD COUNTY, FLORIDA. CASE NO.: IN THE INTEREST OF: Bar Code Label / Minor Child(ren) (___)REPORT OF GENERAL MAGISTRATE UPON PETITION FOR TEMPORARY PARENTAL RESPONSIBILITY OF MINOR CHILD(REN) BY EXTENDED FAMILY (___) REPORT OF GENERAL MAGISTRATE UPON PETITION FOR EMERGENCY TEMPORARY PARENTAL RESPONSIBILITY OF MINOR CHILD(REN) BY EXTENDED FAMILY THIS CAUSE came to be heard on {date}______________________________, 20____, before the undersigned General Magistrate, pursuant to the Court’s Order of Referral, 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: of the minor child(ren) and has 1. Petitioner is the physical parental responsibility of the minor child(ren) to wit: NAME BIRTH DATE 2. This Court has jurisdiction over the above-referenced child(ren). 3. The Mother of the child(ren) is 4. The Mother (___) has (___) has not consented in writing to the entry of this Order for Temporary Parental Responsibility. 5. The Mother is unwilling or unable to consent in writing for the following reasons: 6. The Father of the child(ren) is . . Law 1039 - Rev 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO:____________________ 7. The Father (___) has (___)has not consented in writing to the entry of this Order for Temporary Custody. 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. (___) Custody 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: WHEREUPON, IT IS HEREBY RECOMMENDED: 1. (___) That the Petition for Temporary Custody of the Minor Child(ren) By Extended Family be GRANTED. 2. (___) That the Petition for Emergency Temporary Custody of Minor Child(ren) be GRANTED. 3. (___) That the Petitioner, ____________________________________, be given physical and legal custody until further order of the Court of the minor child(ren) to wit: NAME BIRTH DATE Law 1039 - Rev 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com . 4. (___) Petitioner be AUTHORIZED to obtain necessary medical treatment for the child(ren). 5. (___) Petitioner be AUTHORIZED to 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: A. Medical, dental and psychiatric records; B. Birth certificates and other records; and, C. Educational records. 6. (___) Petitioner be AUTHORIZED to enroll the child(ren) in school and grant or withhold consent for a child to be tested or placed in special school programs, including exceptional education. 7. (___) Petitioner be AUTHORIZED to do all other things necessary for the care of the minor child(ren). 8. (___) 8. (___) 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). WHEREFORE, the undersigned General Master files this report with the office of the Clerk of Court and recommends entry of an order approving it. DATED this _______ day of _____________________________, 200___. ________________________________ General Magistrate cc: _________________________________ _________________________________ _________________________________ Law 1039 - Rev 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com