IN THE CIRCUIT COURT OF THE FIRST JUDICIAL CIRCUIT IN AND FOR ESCAMBIA COUNTY, FLORIDA IN THE INTEREST OF: DOB: CASE NO._________________ Minor Child DOB: DIVISION: • •• Minor Child DOB: Minor Child VERIFIED PETITION FOR TEMPORARY LEGAL CUSTODY OF MINOR CHILD(REN) BY AN EXTENDED FAMILY MEMBER The undersigned petitioner {full legal name}, _______________________________________________, being sworn, certifies the following information is true: 1. This action is filed pursuant to Chapter 751, Florida Statutes, Temporary Custody of Minor Children by Extended Family. 2. I am qualified to file this Petition because I am [ √ only one] : ( ) Extended Family Member: the child, parent, brother, sister, niece, nephew, aunt, uncle, grandparent or great-grandparent of the parent of the child(ren). ( ) The child, parent, brother, sister, niece, nephew, aunt, uncle, grandparent or great-grandparent of the stepparent of the child(ren) who is currently married to the parent of the child(ren) and not a party in a pending dissolution, separate maintenance, domestic violence, or other civil or criminal proceeding in any court of competent jurisdiction involving one or both of the child(ren)'s parents as an adverse party. • 3. (a) The name of the child(ren) is/are:__________________________________________________________ (b) The child(ren)•s date(s) ofof birth is (are): The child(ren)'s date(s) birth is/are:______________________________________________________ 4. The current address of the child(ren) is:_________________________________________________________ ________________________________________________________________________________________ 5. The name(s) and address(es) of the child(ren)'s parents is (are): Mother: Father: ___________________________________ _________________________________ ___________________________________ _________________________________ American LegalNet, Inc. www.FormsWorkflow.com 6. The name(s) and current address(es) of the person(s) with whom the child(ren) has/have lived during the past five (5) years: Dates (From/To) NAME CURRENT ADDRESS 7. The places the child(ren) has/have lived during the past five (5) years: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ √ 8. Information about Other Proceedings: [• •only one ] ____ (a) I HAVE NO INFORMATION of any custody proceedings pending in a court of this state or any other state concerning the child(ren) subject to this proceeding. ____ (b) I HAVE THE FOLLOWING INFORMATION concerning other proceedings pending in a court of this or another state concerning the parents or child(ren) subject to this proceeding: [• all that apply]. √ ( )Temporary or Permanent Custody Order: Court and State:______________________________________________________________________ Date of Court Order or Judgment:________________________________________________________ Case Number:________________________________________________________________________ ( )Temporary or Permanent Child Support Order(s): Court and State:______________________________________________________________________ Date of Court Order of Judgment :________________________________________________________ Case Number:________________________________________________________________________ ( ) Temporary or Permanent Orders for Protection Against Violence entered on behalf of or against either parent, the petitioner, or the child(ren): Court and State:_______________________________________________________________________ Date of Court Order or Judgement:________________________________________________________ Case Number:________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 9. Petitioner•s residence and mailing address: ______________________________________________________ __________________________________________________________________________________________________. 10. Petitioner is related to the child(ren) by virtue of being the parent or stepparent(s) [√ only one] stepparent•s:• ( )child ( )parent ( )brother ( ( )aunt )uncle )grandparent ( ( 11. The consent of the parent(s) ____ is )sister ( ( )niece ( )nephew )great-grandparent ____ is not attached to this Petition OR The specific act or omissions of the parents which demonstrate that the parents have abused, abandoned,or neglected the child(ren) as defined in chapter 39 are: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 12. It is in the best interest of the child(ren) for the petitioner to have custody of the child(ren); and Petitioner requests temporary legal custody of the child(ren) for _____ months _____ indefinitely because: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, Petitioner requests the Court grant temporary legal custody of the above-named child(ren) to the above-named Petitioner, and in doing so to enter an Order vesting the Petitioner with the power to make all necessary provisions for the care of the child(ren) including, but not limited to consenting to reasonable and necessary medical care (including mental health treatment, dental care and non-emergency surgery); securing copies of the child(ren)•s records, the child(ren)'s records, including birth certificates, educational and medical records (including granting or denying consent to special educational programs); and all other things necessary for the adequate care and custody of the child(ren). UNDER PENALTY OF PERJURY, I CERTIFY THE FOREGOING FACTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. American LegalNet, Inc. www.FormsWorkflow.com ________________________________________ PETITIONER•S SIGNATURE _______________________________________________ Petitioner's Name - Printed or Typed ________________________________________ DATE ________________________________________________ Street Address/Mailing Address _______________________________________________ State, City, Zip Code Telephone: (_____) ______________________________________ STATE OF FLORIDA COUNTY OF ESCAMBIA This instrument was acknowledged before me by ___________________________________, ( personally known to me OR ( ) who is ) who has produced ____________________________________________ as identification. ERNIE LEE MAGAHA Clerk of the Circuit Court & Comptroller BY:__________________________________ (SEAL) Deputy Clerk OR ______________________________________ (SEAL) NOTARY PUBLIC - STATE OF FLORIDA American LegalNet, Inc. www.FormsWorkflow.com