Amendments to Florida Supreme Court Approved Family Law Forms, Etc. (Second opinion)

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Supreme Court of Florida ____________ No. SC02-516 ____________ AMENDMENTS TO FLORIDA SUPREME COURT APPROVED FAMILY LAW FORMS--STEPPARENT ADOPTION FORMS. [October 3, 2002] PER CURIAM. In our opinion dated March 28, 2002, Amendments to Florida Supreme Court Approved Family Law Forms--Stepparent Adoption Forms, 821 So. 2d 263 (Fla. 2002), we adopted amendments to the stepparent adoption forms that were necessary due to legislation. We gave interested parties an opportunity to comment on the amendments and we received comments, which we carefully considered, from the Honorable John C. Lenderman, Circuit Judge, Sixth Judicial Circuit, attorney Nancy C. Holliday-Fields, Third Judicial Circuit, and attorney Jeanne Tate on behalf of the Florida Adoption Council. We have jurisdiction. See art. V, § 2(a), Fla. Const. We have considered the comments and adopt many of the suggestions therein, including an amendment to the instructions for form 12.981(b)(1), clearly indicating that the adopting stepparent will continue to have rights, including visitation and custody, where appropriate, should the natural parent and adopting stepparent later divorce. Further, we have changed language in form 12.981(a)(5), subdivision 4, from "address or location" to "current residence." We also have eliminated the requirement in form 12.981(a)(6) that required a sworn statement. With regard to several comments received, we conclude that those comments address subdivisions in the forms that are based on statutory requirements and, thus, we are unable to change those subdivisions without changes in the statutes. Florida Supreme Court Approved Family Law Forms (stepparent adoption forms) 12.981(a)(2), 12.981(a)(5), 12.981(a)(6), 12.981(a)(7), 12.981(b)(1), and 12.981(c)(1) are amended as set forth in the appendix to this opinion, effective for immediate use. Florida Supreme Court Approved Family Law Form 12.981(a)(8), Indian Child Welfare Act Affidavit, is adopted as set forth in the appendix to this opinion, effective for immediate use. We make no changes to the remainder of the Florida Supreme Court Approved Family Law Forms (stepparent adoption forms) that were adopted in our opinion dated March 28, 2002. We express no opinion as to the correctness or applicability of these forms, or on the substance of the legislation. This opinion and the forms may be accessed and downloaded from this Court s website at www.flcourts.org. It is so ordered. ANSTEAD, C.J., SHAW, WELLS, PARIENTE, LEWIS, and QUINCE, JJ., and HARDING, Senior Justice, concur. THE FILING OF A MOTION FOR REHEARING SHALL NOT ALTER THE EFFECTIVE DATE OF THESE AMENDED FORMS. Original Proceeding - Florida Supreme Court Approved Family Law Forms Honorable John C. Lenderman, Circuit Judge, Sixth Judicial Circuit, St. Petersburg, Florida; Nancy C. Holliday-Fields, Attorney, Third Judicial Circuit, Lake City, Florida; and Jeanne Tate, President, The Florida Adoption Council, Tampa, Florida, Responding INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.981(a)(2), TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION: CONSENT AND WAIVER BY PARENT When should this form be used? This form is to be completed and signed by the parent who is giving up all rights to and custody of the minor child to be adopted. This consent shall not be executed before the birth of the minor child. This form should be typed or printed in black ink. It must be signed in the presence of a notary public or deputy clerk and two witnesses other than the notary or clerk. You should file this form with the Petition to Terminate Parental Rights Pending Adoption by Stepparent, O Florida Supreme Court Approved Family Law Form 12.981(a)(1) . After completing this form, you should file the original with the clerk of the circuit court in the county where the Petition to Terminate Parental Rights Pending Adoption by Stepparent, O Florida Supreme Court Approved Family Law Form 12.981(a)(1) is filed and keep a copy for your records. Special notes... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of Disclosure from Nonlawyer, O Florida Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete. Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(2), Termination of Parental Rights Pending Stepparent Adoption: Consent and Waiver by Parent (10/02) IN THE CIRCUIT COURT OF THE IN AND FOR JUDICIAL CIRCUIT, COUNTY, FLORIDA Case No.: Division: IN RE: TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION OF , Minor Child(ren). CONSENT AND WAIVER BY PARENT 1. I, {full legal name} , am the [ / one only] ( ) father or ( ) mother of the minor child(ren) subject to this consent who is/are: Child s Current Name Gender Birth date Birthplace {city, county, state} a. b. c. d. e. f. 2. I relinquish all rights to and custody of this (these) minor child(ren), {name(s)} , with full knowledge of the legal effect of the stepparent adoption and consent to the adoption by the child(ren) s stepparent whose name is: [ / one only] ( ){name} ( ) not required for my granting of this consent. 3. I understand my legal rights as a parent, I have read and understand the following Consent Disclosure, and I understand that I do not have to sign this consent and release of my parental rights. I acknowledge that this consent is being given knowingly, freely, and voluntarily. I further acknowledge that my consent is not given under fraud or duress. I understand that there is a grace period in Florida during which I may revoke my consent. I understand that, in signing this consent, I am permanently and forever giving up all my parental rights to and interest in this (these) minor child(ren). I voluntarily, permanently relinquish all my parental rights to this (these) minor child(ren). Florida Supreme Court Approved Family Law Form 12.981(a)(2), Termination of Parental Rights Pending Stepparent Adoption: Consent and Waiver by Parent (10/02) CONSENT DISCLOSURE This consent is required by Florida Statute to include, (in at least 16point boldfaced type,) all of the following information. The information in this disclosure may not apply to your particular situation. You have the right to select at least one person who does not have an employment, professional, or personal relationship with the adoption entity or the prospective adoptive parents to be present when this affidavit is executed and to sign it as a witness. You must acknowledge on this form that you were notified of this right and you must indicate the witness or witnesses you selected, if any. If you are selecting a witness, the witness you select is {full legal name} . You do not have to sign this consent form. You may do any of the following instead of signing this consent or before signing this consent: 1. Consult with an attorney; 2. Hold, care for, and feed the child; 3. Place the child in foster care or with any friend or family member you choose who is willing to care for the child; 4. Take the child home unless otherwise legally prohibited; and 5. Find out about the community resources that are available to you if you do not go through with the termination of parental rights and adoption. If you sign this consent, you are giving up all rights to your child. Your consent is valid and binding unless withdrawn as permitted by law. If you are giving up your rights to a child who is to be placed for adoption with identified prospective adoptive parents upon the child s release from a licensed hospital or birth center following birth, a waiting period will be imposed before you may sign the consent for Florida Supreme Court Approved Family Law Form 12.981(a)(2), Termination of Parental Rights Pending Stepparent Adoption: Consent and Waiver by Parent (10/02) adoption. You must wait 48 hours from the time of birth, or until the birth mother has been notified in writing, either on her patient chart or in release papers, that she is fit to be released from a licensed hospital or birth center, whichever is sooner, before you may sign the consent for adoption. Once you have signed the consent, it is valid and binding and cannot be withdrawn unless a court finds that it was obtained by fraud or under duress. If you are giving up your rights to a child who is not placed for adoption upon the child s release from a licensed hospital or birth center following birth, you may sign the consent at any time after the birth of the child. While the consent is valid and binding when signed, you have time to change your mind. This time is called the revocation period. When the revocation period applies, you may withdraw your consent for any reason at any time prior to the placement of the child with the prospective adoptive parents, or if you do it within 3 business days after the date you signed the consent or 1 business day after the date of the birth mother s discharge from a licensed hospital or birth center, whichever is later. To withdraw your consent during the revocation period, you must: 1. Notify the adoption entity, by writing a letter, that you are withdrawing your consent. 2. Mail the letter at a United States Post Office within 3 business days after the date you signed the consent or 1 business day after the date of the birth mother s discharge from a licensed hospital or birth center, whichever is later. The term business day means any day on which the United States postal service accepts certified mail for delivery. 3. Send the letter by certified United States mail with return receipt requested. 4. Pay postal costs at the time you mail the letter. 5. Keep the certified mail receipt as proof that consent was withdrawn in a timely manner. Florida Supreme Court Approved Family Law Form 12.981(a)(2), Termination of Parental Rights Pending Stepparent Adoption: Consent and Waiver by Parent (10/02) Once the revocation period is over, or the child has been placed with the prospective adoptive parents, whichever occurs later, you may not withdraw your consent unless you can prove in court that consent was obtained by fraud or duress. 4. I consent, release, and give up permanently, of my own free will, my parental rights to this (these) minor child(ren), for the purpose of stepparent adoption. 5. I waive any further notice of the stepparent adoption proceeding. I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this consent and waiver and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Parent Printed Name: Address: City, State, Zip: Telephone Number: Fax Number: Signature of Witness Printed Name: Business Address: Home Address: Driver s License or State ID Card No.: Signature of Witness Printed Name: Business Address: Home Address: Driver s License or State ID Card No.: STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on {date} at {time} NOTARY PUBLIC or DEPUTY CLERK [Print, type, or stamp commissioned name of notary or deputy clerk.] Personally known Produced identification Florida Supreme Court Approved Family Law Form 12.981(a)(2), Termination of Parental Rights Pending Stepparent Adoption: Consent and Waiver by Parent (10/02) . Type of identification produced I hereby acknowledge receipt of a copy of this executed Consent and Waiver. Signature of Parent IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ N fill in all blanks] I, {full legal name and trade name of nonlawyer} a nonlawyer, located at {street} , {city} {state} , {phone} , helped {name} fill out this form. Florida Supreme Court Approved Family Law Form 12.981(a)(2), Termination of Parental Rights Pending Stepparent Adoption: Consent and Waiver by Parent (10/02) , , , INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.981(a)(5), TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION: AFFIDAVIT OF DILIGENT SEARCH When should this form be used? Use this form to obtain constructive service (also called service by publication) in a case to terminate parental rights pending stepparent adoption, Petition to Terminate Parental Rights Pending Adoption by Stepparent,O Florida Supreme Court Approved Family Law Form 12.981(a)(1), when any required consent is unavailable because the address or location of the person whose consent is required is not known and cannot be determined. This form includes a checklist of places you must look for information on the location of the person whose rights you seek to terminate. You do have to look in all of these places, and the court must believe that you have made a very serious effort to get information about the person s location and that you have followed up on any information you received. This form should be typed or printed in black ink. After completing this form, you should file the original with the clerk of the circuit court in the county where your petition was filed and keep a copy for your records. Where can I look for more information? Before proceeding, you should read General Information for Self-Represented Litigants found at the beginning of these forms. For further information, see rule 12.070, Florida Family Law Rules of Procedure and Rule 1.070, Florida Rules of Civil Procedure. Special notes... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, O Florida Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete. Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(5), Termination of Parental Rights Pending Stepparent Adoption: Affidavit of Diligent Search (10/02) IN THE CIRCUIT COURT OF THE IN AND FOR JUDICIAL CIRCUIT, COUNTY, FLORIDA Case No.: Division: IN RE: TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION OF , Minor Child(ren). TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION: AFFIDAVIT OF DILIGENT SEARCH I, {full legal name} following information is true: 1. 2. , being sworn, certify that the I am the child(ren) s ( ) mother ( ) father. The last known address of the child(ren) s other parent {name} as of {date} , was: Address City Telephone No. , State Zip Fax No. His/her last known employment, as of {date} , was: Name of Employer Address Telephone No. City State Zip Fax No. 3. The other parent is over the age of 18. 4. The other parent s current residence is not known and cannot be determined, although I have made a diligent search and inquiry to locate him/her through the following: You must search ALL of the following sources of information and state the results. United States Post Office inquiry through the Freedom of Information Act for the person s current address or any previous address. Result of search: Last known employment of the other parent, including name and address of employer. Addresses to which W-2 Forms or other wage and earning statements were mailed, and, if a pension or profitsharing plan exists, then to what address any pension or plan payment is to be mailed. Result of Florida Supreme Court Approved Family Law Form 12.981(a)(5), Termination of Parental Rights Pending Stepparent Adoption: Affidavit of Diligent Search (10/02) search: Regulatory agencies, including professional or occupational licensing, in the area where the other parent last resided. Result of search: Names and addresses of relatives to the extent such can be reasonably obtained from the petitioner or other sources, contacts with those relatives and inquiry as to the other parent s last known address. You are to follow up any leads of any addresses where the other parent may have moved. Relatives include, but are not limited to: parents, brothers, sisters, aunts, uncles, cousins, nieces, nephews, grandparents, great-grandparents, former or current in-laws, stepparents, and stepchildren. Result of search: Information about the other parent s possible death and, if dead, the date and location. Telephone listings in the area where the other parent last resided. Result of search: Law enforcement agencies in the area where the other parent last resided. Result of search: Highway Patrol records in the state where the other parent last resided. Result of search: Department of Corrections records in the state where the other parent last resided. Result of search: Hospitals in the last known area of the other parent s residence. Result of search: Records of utility companies, which include water, sewer, cable TV, and electric in the last known area of the other parent s residence. Result of search: Records of the Armed Forces of the U.S. and their response as to whether or not there is any information about the other parent. (See Florida Supreme Court Approved Family Law Form 12.912(a), Memorandum for Certificate of Military Service.) Result of search: Records of the tax assessor s and tax collector s office in the area where the other parent last resided. Result of search: Search of one Internet databank locator service. Result of search: Information held by all medical providers who rendered medical treatment or care to the mother and child, including the identity and location information of all persons listed by the mother as being financially responsible for the uninsured expenses of treatment or care and all persons who made such payments. Result of search: Title IV-D (child support enforcement) agency records in the state of the other parent s last known address. Result of search: I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit 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: Florida Supreme Court Approved Family Law Form 12.981(a)(5), Termination of Parental Rights Pending Stepparent Adoption: Affidavit of Diligent Search (10/02) Fax Number: STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on by . NOTARY PUBLIC or DEPUTY CLERK [Print, type, or stamp commissioned name of notary or deputy clerk.] Personally known Produced identification Type of identification produced IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ N fill in all blanks] I, {full legal name and trade name of nonlawyer} , a nonlawyer, located at {street} , {city} , {state} , {phone} , helped {name} , who is the petitioner, fill out this form. Florida Supreme Court Approved Family Law Form 12.981(a)(5), Termination of Parental Rights Pending Stepparent Adoption: Affidavit of Diligent Search (10/02) INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.981(a)(6), NOTICE OF PETITION TO TERMINATE PARENTAL RIGHTS PENDING STEPPARENT ADOPTION AND NOTICE OF HEARING When should this form be used? For each person whose written consent is required, who has not executed an affidavit of nonpaternity, and whose location and identity is known, you must notify him or her of this proceeding. Additionally, this form should be used to notify those persons whose consent is required and who have not properly consented. This form should be typed or printed in black ink. You should then file the original and 1 copy with the clerk of the circuit court in the county where the Petition to Terminate Parental Rights Pending Stepparent Adoption O Florida Supreme Court Approved Family Law Form 12.981(a)(1) is filed. A copy of this form must be personally served by personal service, at least 30 days before the hearing upon: C anyone from whom consent is required who has not executed an affidavit of nonpaternity, whose location and identity have been determined. If you absolutely cannot find an address or location for the parent, you may use constructive service. For more information about personal and constructive service, you should refer the General Instructions for Self-Represented Litigants found at the beginning of these forms and the instructions to Summons: Personal Service on an Individual,O Florida Family Law Rules of Procedure Forms 12.910(a) and Affidavit of Diligent Search, O Florida Supreme Court Approved Family Law Form 12.981(a)(5). However, the law regarding constructive service is very complex and you may wish to consult an attorney regarding that issue. Where can I look for more information? Before proceeding, you should read General Information for Self-RepresentedLitigants found at the beginning of these forms. See chapter 63, Florida Statutes, and Florida Family Law Rule 12.200(a)(2) for further information. Special notes... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, O Florida Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete. Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(6), Notice of Petition to Terminate Parental Rights Pending Stepparent Adoption (10/02) IN THE CIRCUIT COURT OF THE IN AND FOR JUDICIAL CIRCUIT, COUNTY, FLORIDA Case No.: Division: IN RE: TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION OF , Minor Child(ren). NOTICE OF PETITION TO TERMINATE PARENTAL RIGHTS PENDING STEPPARENT ADOPTION AND NOTICE OF HEARING A petition to terminate parental rights pending adoption by stepparent has been filed. A copy of the petition is being served with this notice. There will be a hearing on the Petition to terminate parental rights pending adoption by stepparent before Judge {name} , , at {time} on {date} Courthouse. The court has reserved hour(s)/ m., in Room of the minutes for this hearing. If you executed a consent to adoption or an affidavit of nonpaternity and a waiver of venue, you have the right to request that the hearing on the petition to terminate parental rights be transferred to the county in which you reside. You may object by appearing at the hearing or filing a written objection with the court. UNDER SECTION 63.089, FLORIDA STATUTES, FAILURE TO FILE A WRITTEN RESPONSE TO THIS NOTICE WITH THE COURT OR TO APPEAR AT THIS HEARING CONSTITUTES GROUNDS UPON WHICH THE COURT SHALL END ANY PARENTAL RIGHTS YOU MAY HAVE REGARDING THE MINOR CHILD. This part to be filled out by the court or to be filled in with information you obtained from the court: If you are a person with a disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact {name} , , {telephone} , {address} within 2 working days of your receipt of this Notice of Hearing. If you are hearing or voice impaired, call TDD 1-800-955-8771. Signature of Party Printed Name: Address: City, State, Zip: Telephone Number: Florida Supreme Court Approved Family Law Form 12.981(a)(6), Notice of Petition to Terminate Parental Rights Pending Stepparent Adoption (10/02) Fax Number: IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ N fill in all blanks] I, {full legal name and trade name of nonlawyer} , , {city} , a nonlawyer, located at {street} , {phone} , helped {name} , {state} who is the petitioner, fill out this form. Florida Supreme Court Approved Family Law Form 12.981(a)(6), Notice of Petition to Terminate Parental Rights Pending Stepparent Adoption (10/02) IN THE CIRCUIT COURT OF THE IN AND FOR JUDICIAL CIRCUIT, COUNTY, FLORIDA Case No.: Division: IN RE: TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION OF , Minor Child(ren). FINAL JUDGMENT TERMINATING PARENTAL RIGHTS PENDING STEPPARENT ADOPTION Upon consideration of the Petition for Termination of Parental Rights Pending Stepparent Adoption and the evidence presented, the Court finds by clear and convincing evidence that: 1. The Court has subject matter jurisdiction over the Petition for Termination of Parental Rights Pending Stepparent Adoption. 2. The Court has jurisdiction over the minor child(ren), {name(s)} {date(s) of birth} . 3. The (___) mother (___) father was served with or waived notice of this action. 4. The parent s parental rights should be terminated because: [ / all that apply] a. Each person whose consent is required has executed a valid consent that has not been withdrawn. b. The person whose consent is required has executed an affidavit of nonpaternity. c. The birth parent abandoned the child(ren) as defined in s. 63.032. d. The parent has been declared incapacitated by a court order, and restoration of capacity is medically improbable. A copy of the order has been filed in this case. e. The legal guardian or lawful custodian of the minor child(ren), other than a parent, has failed to respond in writing to a request for consent for a period of 60 days, or his/her reasons for withholding consent are unreasonable. f. The person to be adopted is married. The spouse of the person to be adopted has failed to consent and the failure of the spouse to consent to the adoption is excused because of prolonged, unexplained absence, unavailability, incapacity, or another circumstance constituting unreasonable withholding of consent. {Explain}: 5. g. The birth parent died on {date} , in County, {state} . {This space is included for the judge to include specific findings of fact} Florida Supreme Court Approved Family Law Form 12.981(a)(7), Final Judgment Terminating Parental Rights Pending Stepparent Adoption (10/02) , NOW, THEREFORE, IT IS ORDERED that: 1. All legal relations between the child(ren) and the noncustodial parent, {name} and between the child(ren) and the relatives of that parent, are terminated, as are all parental rights and responsibilities of that parent. 2. This court retains jurisdiction over the subject matter and over the minor child(ren) until a final judgment is entered on the stepparent adoption. ORDERED on . CIRCUIT JUDGE Florida Supreme Court Approved Family Law Form 12.981(a)(7), Final Judgment Terminating Parental Rights Pending Stepparent Adoption (10/02) INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.981(a)(8), INDIAN CHILD WELFARE ACT AFFIDAVIT When should this form be used? This form should be used in cases involving termination of parental rights pending stepparent adoption of a child. This affidavit is required. This form should be typed or printed in black ink. After completing this form, you should sign the form before a notary public or deputy clerk. You should then file the original with the clerk of the circuit court in the county where the petition was filed and keep a copy for your records. What should I do next? A copy of this form must be mailed or hand delivered to the other party in your case, if it is not served on him or her with your initial papers. Where can I look for more information? Before proceeding, you should read General Information for Self-Represented Litigants found at the beginning of these forms. The words that are in bold underline in these instructions are defined there. Special notes... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, O Florida Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete. Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(8), Indian Child Welfare Act Affidavit (10/02) IN THE CIRCUIT COURT OF THE IN AND FOR JUDICIAL CIRCUIT, COUNTY, FLORIDA Case No.: Division: , Petitioner, and , Respondent. INDIAN CHILD WELFARE ACT AFFIDAVIT I, {full legal name} are true: , being sworn, certify that the following statements {name} subject to this proceeding: [ / Upon information and belief the child 1. one only] is not an Indian child. The Indian Child Welfare Act does not apply to this proceeding. is an Indian child within the meaning of the Indian Child Welfare Act of 1978 (25 U.S.C. §1901 et seq.). I certify that a copy of this document was [ / one only] ( ) mailed ( ) faxed and mailed ( ) hand delivered to the person(s) listed below on {date} . Other party or his/her attorney: Name: Address: City, State, Zip: Fax Number: I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Party Printed Name: Address: City, State, Zip: Telephone Number: Fax Number: STATE OF FLORIDA Florida Supreme Court Approved Family Law Form 12.981(a)(8), Indian Child Welfare Act Affidavit (10/02)

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