Title: In Re: Amendments To The Florida Supreme Court Approved Family Law Forms
Citation: N/A
Docket Number: SC10-2344
State: Florida
Issuer: Florida Supreme Court
Date: April 7, 2011

Supreme Court of Florida 
 
 
____________ 
 
No. SC10-2344 
____________ 
 
 
IN RE:  AMENDMENTS TO THE FLORIDA SUPREME COURT 
APPROVED FAMILY LAW FORMS.   
 
[April 7, 2011] 
 
PER CURIAM. 
 
Pursuant to the procedures approved by this Court in Amendments to the 
Florida Family Law Rules of Procedure & Family Law Forms, 810 So. 2d 1, 14 
(Fla. 2000), this Court has internally reviewed the Florida Supreme Court 
Approved Family Law Forms and has determined that new forms pertaining to 
petitions for temporary or concurrent custody should be adopted.  We received 
input on these issues from the Advisory Workgroup on the Florida Supreme Court 
Approved Family Law Forms, which provided valuable assistance. We have 
jurisdiction.  See art. V, § 2(a), Fla. Const. 
 
In chapter 2010-30, Laws of Florida, the Florida Legislature adopted 
amendments to Chapter 751, Florida Statutes, related to the issue of temporary and 
 
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concurrent child custody.1  Specifically, in chapter 2010-30, the legislature 
amended sections 751.01, 751.011, 751.02, 751.03, and 751.05, Florida Statutes; 
as amended, these sections set forth the procedures for filing petitions for 
temporary and concurrent custody arrangements; the notice and opportunity to be 
heard that must be afforded to the child’s parents; and the trial court’s 
responsibilities in considering the petition.  Upon consideration of these 
amendments, we adopt the following new Supreme Court Approved Family Law 
Forms: form 12.970(a) (Petition for Temporary Custody by Extended Family); 
form 12.970(b) (Petition for Concurrent Custody by Extended Family); form 
12.970(c) (Waiver of Service of Process and Consent for Temporary Custody by 
Extended Family); form 12.970(d) (Waiver of Service of Process and Consent for 
Concurrent Custody by Extended Family); form 12.970(e) (Order Granting 
Petition for Temporary Custody by Extended Family); and form 12.970(f) (Order 
Granting Petition for Concurrent Custody by Extended Family). 
 
The new forms are adopted as set forth in the appendix to this opinion, fully 
engrossed and ready for use.  The forms shall become effective immediately upon 
the release of this opinion.  The forms may also be accessed and downloaded from 
the Florida State Court’s website at 
                                          
 
 
1.  The legislative amendments took effect July 1, 2010.  See Ch. 2010-30, § 
9, Laws of Fla.  
 
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www.flcourts.org/gen_public/family/forms_rules/index.shtml.  By adoption of the 
new forms, we express no opinion as to their correctness or applicability.  We also 
direct that the new forms be published for comment.  Interested persons shall have 
sixty days from the date of this opinion to file comments with the Court.2 
It is so ordered. 
CANADY, C.J., and PARIENTE, LEWIS, QUINCE, POLSTON, LABARGA, 
and PERRY, JJ., concur. 
 
THE FILING OF A MOTION FOR REHEARING SHALL NOT ALTER THE 
EFFECTIVE DATE OF THESE AMENDMENTS. 
 
 
Original Proceeding – Florida Supreme Court Family Law Forms 
 
Steven Patrick Combs, Chair, the Family Law Rules Committee, Jacksonville, 
Florida, 
 
 
for Petitioner 
 
 
                                          
 
 
2.  An original and nine paper copies of all comments must be filed with the 
Court on or before June 6, 2011, as well as a separate request for oral argument if 
the person filing the comment wishes to participate in oral argument, which may 
be scheduled in this case.  Electronic copies of all comments also must be filed in 
accordance with the Court's administrative order In re Mandatory Submission of 
Electronic Copies of Documents, Fla. Admin. Order No. AOSC04-84 (Sept. 13, 
2004). 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By 
Extended Family (04/11) 
 
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APPENDIX 
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW 
FORM 12.970(a), PETITION FOR TEMPORARY CUSTODY BY EXTENDED 
FAMILY (04/11) 
 
When should this form be used? 
 
This form should be used by an extended family member to obtain temporary custody of a child or 
children pursuant to Chapter 751, Florida Statutes.  This form should not be used if you are a parent 
seeking to establish parental responsibility or time-sharing with a child or children.   
 
An Extended Family Member is: 
A relative of a minor child within the third degree by blood or marriage to the parent;  
OR 
The stepparent of a minor child if the stepparent is currently married to the parent of the child and is 
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. 
 
You may file a Petition for Temporary Custody if: 
You have the signed, notarized consents of the child(ren)’s legal parents; 
OR 
You are an extended family member who is caring full time for the child(ren) in the role of a substitute 
parent and with whom the child(ren) is (are) presently living. 
 
If one of the minor child(ren)’s parents objects to the Petition, the court shall grant the Petition only 
upon a finding, by clear and convincing evidence, that the child(ren)’s parent or parents are unfit to 
provide for the care and control of the child(ren).  In determining that a parent is unfit, the court must 
find that the parent has abused, abandoned, or neglected the child(ren), as defined in Chapter 39, 
Florida Statutes.  If you do not have the parents’ consents you should consult a family law attorney 
before you file your papers. 
 
If you do not meet the qualifications above, you should talk to an attorney about other options.  You 
may also report any suspected abuse, abandonment, or neglect to the appropriate authorities. 
 
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 file  the original with the clerk of the circuit court in 
the county where you live and keep a copy for your records. 
 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By 
Extended Family (04/11) 
 
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What should I do next? 
 
IF YOU HAVE SIGNED AND NOTARIZED WAIVERS OF SERVICE OF PROCESS AND CONSENTS from the 
child(ren)’s mother and father, and the case is uncontested, you may call the clerk, family law intake 
staff, or judicial assistant, to set a final hearing.  You must notify the child(ren)’s parents of the hearing 
by using a Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or 
other appropriate notice of hearing form. 
 
If one of the parents is deceased, you must file a certified copy of the proof of death. 
 
IF YOU DO NOT HAVE SIGNED AND NOTARIZED WAIVERS OF SERVICE OF PROCESS AND CONSENTS from 
the child(ren)’s parents, you must properly notify the parents of the petition. If you know where he or 
she lives, you should use personal service.  If you absolutely do not know where he or she lives after 
conducting a diligent search, you may use constructive service.   You must complete all of the searches 
listed in the Affidavit of Diligent Search and Inquiry, Florida Family Law Rules of Procedure Form 
12.913(b), and file the form with the clerk.  You should seek legal advice on constructive service as this is 
a complicated area of the law.  If the identity of one parent is unknown, you will need to seek legal 
advice to determine the proper way to serve an unknown parent. For more information, see Chapter 49, 
Florida Statutes. 
 
If personal service is used, the parents have 20 days to answer after being served with your petition.  
Your case will generally proceed in one of the following ways: 
 
DEFAULT. . . If after 20 days, no answer has been filed, you may file a Motion for Default, Florida 
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court.  You must file a Notice for 
Trial, Florida Supreme Court Approved Family Law Form 12.924.  Then, if you have filed all of the 
required papers, you may call the clerk, family law intake staff, or judicial assistant, to set a final 
hearing.  You must notify the child(ren)’s parents of the hearing by using a Notice of Hearing (General), 
Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form. 
 
CONTESTED. . . If either parent files an answer which disagrees with or denies anything in your petition, 
and you are unable to settle the disputed issues, you must file a Notice for Trial, Florida Supreme Court 
Approved Family Law Form 12.924, to request a final hearing.  Some circuits may require the completion 
of mediation before a final hearing may be set.  You should contact the clerk, family law intake staff, or 
judicial assistant for instructions on how to set your case for trial (final hearing). 
 
At any time, either or both of the child(ren)’s parents may petition the court to modify or terminate the 
order granting temporary custody.  The court shall terminate the order upon a finding that the parent is 
a fit parent, or by the consent of the parties.  The court may modify an order granting temporary 
custody if the parties consent or if the modification is in the best interest of the child(ren). 
 
Where can I look for more information? 
 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By 
Extended Family (04/11) 
 
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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.  
For further information, see Chapter 751 and Chapter 39, Florida Statutes. 
Special Notes. . . 
 
If you do not have the money to pay the filing fee, you may obtain an application for Determination of 
Civil Indigent Status, fill it out, and the clerk will determine whether you are eligible to have filing fees 
deferred. 
 
With this petition, you must file the following and provide a copy to the other party: 
 
Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme 
Court Approved Family Law Form 12.902(d). 
 
Notice of Related Cases, Florida Family Law Rules of Procedure Form 12.900(h). 
 
Family Court Cover Sheet, Florida Family Law Rules of Procedure Form 12.928. 
 
Non-Military Affidavit, Florida Supreme Court Approved Family Law Form 12.912(b). (Required 
only for obtaining a default on petitions that have been personally or constructively served.  Not 
required if both parents have signed a waiver and consent)  
 
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, Florida Family Law Rules 
of Procedure Form 12.900(a), before he or she helps you.  A nonlawyer helping you fill out these forms  
must also 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. 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family 
(04/11) 
 
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IN THE CIRCUIT COURT OF THE _______________  JUDICIAL CIRCUIT, 
IN AND FOR _______________________________ COUNTY, FLORIDA 
 
 
 
 
 
 
 
 
 
Case No: _______________________ 
 
 
 
 
 
 
 
 
Division: _______________________ 
 
__________________________________, 
 
 
 
Petitioner, 
and 
__________________________________, 
 
 
 
Respondent/Mother, 
 
__________________________________, 
 
 
 
Respondent/Father. 
 
 
PETITION FOR TEMPORARY CUSTODY BY EXTENDED FAMILY 
 
 
 
Petitioner, {full legal name} _________________________________, being sworn, certifies that 
the following information is true: 
1. This is an action for temporary custody pursuant to Chapter 751, Florida Statutes. 
 
2. Petitioner requests temporary custody of the following minor child(ren): 
Name  
 
 
Date of Birth 
 
Current Address 
__________________________________________________________________________ 
__________________________________________________________________________ 
__________________________________________________________________________ 
__________________________________________________________________________ 
 
3. Petitioner completed a Uniform Child Custody Jurisdiction and Enforcement Act Affidavit, 
Florida Supreme Court Approved Family Law Form 12.902(d), which was filed with this Petition.  
The affidavit includes the names and current addresses of the persons with whom the child(ren) 
has(have) lived during the past 5 years, the places where the child(ren) has(have) lived during 
the past 5 years, and information concerning any custody proceeding in this or any other state 
with respect to the child(ren). If the Affidavit is not completely filled out, signed under oath, 
and filed with the Petition, the case may be dismissed without hearing. 
 
4. Petitioner is an extended family member who is: [Choose one only] 
_____ Related to the minor child(ren) within the third degree by blood or marriage to a parent; 
OR 
_____ The stepparent of the minor child(ren), is married to the (   )Mother (   )Father and is 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. 
 
Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family 
(04/11) 
 
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5. Petitioner’s relationship to the minor child(ren) is: ____________________________________. 
 
6. The residence and post office address of the Petitioner is: ______________________________ 
____________________________________________________________________________. 
 
7. Petitioner is a proper person to be awarded temporary custody because: [Choose one only] 
____ 
Petitioner has the signed, notarized consent from both of the child(ren)’s legal parents; 
OR 
____ 
Petitioner is caring full time for the child(ren) in the role of a substitute parent and the 
child(ren) currently live with the Petitioner. 
If Petitioner does not have the signed consents from both parents or is not caring for the 
child(ren) full time as a substitute parent, Petitioner cannot obtain temporary custody under 
Chapter 751, Florida Statutes.  Petitioner should consult an attorney about other options. 
 
8. The legal mother of the child(ren) is ____________________________________, whose current 
address is: _____________________________________________________________________. 
 
9. The legal father of the child(ren) is ______________________________________, whose 
current address is:  ___________________________________________________________. 
 
10. The Consents of ______Father and/or _________ Mother is/are attached to the Petition. 
OR 
{If Applicable} The Consent of the _________________ is not attached because that parent is 
deceased. A certified copy of the proof of death is attached. 
OR 
Consent has NOT been obtained from the parents.  The specific acts or omissions of the parents 
which demonstrate that the parents have abused, abandoned, or neglected the child(ren) as 
defined in Chapter 39, Florida Statutes are: (attach additional sheets if necessary) 
________________________________________________________________________ 
_____________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________. 
 
11. Petitioner requests temporary custody be granted for the following period of time:___________ 
___________________________________________________________________________.  
The reasons that support this request are: ___________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________. 
 
12. It is in the best interests of the child(ren) that the Petitioner have temporary custody of the 
child(ren) for the following reasons: _______________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________. 
Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family 
(04/11) 
 
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13. ORDER OF PROTECTION 
___ 
Petitioner IS NOT aware of any temporary or permanent order for protection entered 
on behalf of or against either parent, the Petitioner, or the child(ren) in Florida or any 
other jurisdiction. 
 
OR 
___ 
Petitioner IS aware of the following temporary or permanent orders for protection 
entered on behalf of or against either parent, the Petitioner, or the child(ren) in Florida 
or any other jurisdiction. The court entering the order and the case number is: _______ 
________________________________________________________________________ 
________________________________________________________________________ 
_______________________________________________________________________. 
 
14. TEMPORARY OR PERMANENT CHILD SUPPORT ORDERS 
___ 
Petitioner IS NOT aware of any temporary or permanent orders for child support for the 
minor child(ren). 
 
OR 
___ 
Petitioner IS aware of the following temporary or permanent order for child support for 
the minor child(ren).  The court entering the order and the case number is:_________ 
 
_______________________________________________________________________ 
 
________________________________________________________________________ 
 
_______________________________________________________________________. 
 
15. CHILD SUPPORT [Choose one only] 
(You  must have proof or waiver of service of process upon the parent(s) or a Waiver of Service 
of Process and Consent for the court to consider an award for child support) 
 
___ 
Petitioner requests the court to order the parents to pay child support. 
___ 
Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing 
child support obligation to the Petitioner. 
___ 
Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing 
child support obligation to the Petitioner, and to award the Petitioner child support 
arrearages. 
 
16. Petitioner ____ requests _____ does not request that the court establish reasonable visitation 
or a time-sharing schedule with the parents. 
 
17. Other 
_____________________________________________________________________________ 
_____________________________________________________________________________ 
_____________________________________________________________________________ 
_____________________________________________________________________________. 
 
 
Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family 
(04/11) 
 
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WHEREFORE, Petitioner requests that this Court grant the Petitioner temporary custody of the 
child(ren) subject to this proceeding; award the Petitioner other relief as requested; and award any 
other relief that the Court deems necessary. 
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 Code: ________________________ 
 
 
 
 
 
 
Telephone Number: _________________________ 
 
 
 
 
 
 
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: [fill in 
all blanks] 
I, {full legal name and trade name of nonlawyer} ___________________________________________ 
a nonlawyer, whose address is{street} ________________________________________________,  
{city} _______________________, {state} ___________, {phone} ________________________, helped 
{name} ______________________________________________ who is the Petitioner, fill out this form. 
 
 
 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By 
Extended Family (04/11) 
 
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW 
FORM 12.970(b), PETITION FOR CONCURRENT CUSTODY BY EXTENDED 
FAMILY (04/11) 
 
When should this form be used? 
 
This form should be used by an extended family member to obtain concurrent custody of a child or 
children pursuant to Chapter 751, Florida Statutes.  This form should not be used if you are a parent 
seeking to establish parental responsibility or time-sharing with a child or children.  “Concurrent 
custody” means that an eligible extended family member is awarded custodial rights to care for a child 
or children concurrently with the child(ren)’s parent or parents. 
 
An Extended Family Member is: 
A relative of a minor child within the third degree by blood or marriage to the parent;  
OR 
The stepparent of a minor child if the stepparent is currently married to the parent of the child and is 
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. 
 
You may file a Petition for Concurrent Custody if: 
You have the signed, notarized consents of the child(ren)’s legal parents; 
OR 
You are an extended family member who is caring full time for the child(ren) in the role of a substitute 
parent and with whom the child(ren) is (are) presently living. 
 
In addition, you must currently have physical custody of the child(ren) and have had physical custody of 
the child(ren) for at least 10 days in any 30-day period within the last 12 months; and not have signed, 
written documentation from a parent which is sufficient to enable you to do all the things necessary to 
care for the child(ren). 
 
If you do not meet the qualifications above, you should talk to an attorney about other options.  You 
may also report any suspected abuse, abandonment, or neglect to the appropriate authorities. 
 
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 file  the original with the clerk of the circuit court in 
the county where you live and keep a copy for your records. 
 
What should I do next? 
 
IF YOU HAVE SIGNED AND NOTARIZED WAIVERS OF SERVICE OF PROCESS AND CONSENTS from the 
child(ren)’s mother and father, you may call the clerk, family law intake staff, or judicial assistant, to set 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By 
Extended Family (04/11) 
 
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a final hearing.  You must notify the child(ren)’s parents of the hearing by using a Notice of Hearing 
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of 
hearing form. 
 
If one of the parents is deceased, you must file a certified copy of the proof of death. 
 
If one of the minor child(ren)’s parents objects to the Petition for Concurrent Custody in writing, the 
court may not grant the petition even if the other parent consents, in writing, to the entry of the order.  
If a parent objects, you have the option of converting the Petition to a Petition for Temporary Custody 
by Extended Family, Florida Supreme Court Approved Family Law Form 12.970(a). If the Petition is not 
converted into a Petition for Temporary Custody by Extended Family, it shall be dismissed without 
prejudice. 
 
At any time, the Petitioner or either or both of the child(ren)’s parents may move the court to terminate 
the order granting concurrent custody.  The court shall terminate the order upon a finding that either or 
both of the child(ren)’s parents objects to the order.  The fact that the order for concurrent custody has 
been terminated does not preclude any person who is otherwise eligible to petition for temporary 
custody from filing such petition. 
 
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.  
For further information, see Chapter 751 and Chapter 39, Florida Statutes. 
 
Special Notes. . . 
 
If you do not have the money to pay the filing fee, you may obtain an application for Determination of 
Civil Indigent Status, fill it out, and the clerk will determine whether you are eligible to have filing fees 
deferred. 
 
With this petition, you must file the following and provide a copy to the other party: 
 
Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme 
Court Approved Family Law Form 12.902(d). 
 
Notice of Related Cases, Florida Family Law Rules of Procedure Form 12.900(h). 
 
Family Court Cover Sheet, Florida Family Law Rules of Procedure Form 12.928. 
 
Non-Military Affidavit, Florida Supreme Court Approved Family Law Form 12.912(b). (Required 
only for obtaining a default on petitions that have been personally or constructively served.  Not 
required if both parents have signed a waiver and consent.)  
 
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, Florida Family Law Rules 
of Procedure Form 12.900(a), before he or she helps you.  A nonlawyer helping you fill out these forms  
Instructions for Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By 
Extended Family (04/11) 
 
- 13 - 
must also 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. 
 
Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family 
 (04/11) 
 
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IN THE CIRCUIT COURT OF THE _______________  JUDICIAL CIRCUIT, 
IN AND FOR _______________________________ COUNTY, FLORIDA 
 
 
 
 
 
 
 
 
 
Case No: _______________________ 
 
 
 
 
 
 
 
 
Division: _______________________ 
 
__________________________________, 
 
 
 
 
     Petitioner, 
and 
__________________________________, 
 
 
 
Respondent/Mother, 
 
__________________________________, 
 
 
 
Respondent/Father. 
 
 
PETITION FOR CONCURRENT CUSTODY BY EXTENDED FAMILY 
 
 
Petitioner, {full legal name} _________________________________, being sworn, certifies that 
the following information is true: 
 
1. This is an action for concurrent custody pursuant to Chapter 751, Florida Statutes. 
 
2. Petitioner requests concurrent custody of the following minor child(ren): 
Name  
 
 
Date of Birth 
 
Current Address 
__________________________________________________________________________ 
__________________________________________________________________________ 
__________________________________________________________________________ 
__________________________________________________________________________ 
 
3. Petitioner completed a Uniform Child Custody Jurisdiction and Enforcement Act Affidavit, 
Florida Supreme Court Approved Family Law Form 12.902(d), which was filed with this Petition.  
The affidavit includes the names and current addresses of the persons with whom the child(ren) 
has (have) lived during the past 5 years, the places where the child(ren) has(have) lived during 
the past 5 years, and information concerning any custody proceeding in this or any other state 
with respect to the child(ren). If the Affidavit is not completely filled out, signed under oath, 
and filed with the Petition, the case may be dismissed without a hearing. 
 
4. Petitioner is an extended family member who is: [Choose one only] 
_____ Related to the minor child(ren) within the third degree by blood or marriage to a parent; 
OR 
_____ The stepparent of the minor child(ren), is married to the (   )Mother (   )Father and is 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. 
 
Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family 
 (04/11) 
 
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5. Petitioner’s relationship to the minor child(ren) is: ____________________________________. 
 
6. The residence and post office address of the Petitioner is: ______________________________ 
______________________________________________________________________________. 
 
7. The legal mother of the child(ren) is _____________________________________, whose 
current address is:__________________________________________________________. 
 
8. The legal father of the child(ren) is ______________________________________, whose 
current address is:  ______________________________________________________________. 
 
9. Petitioner currently has physical custody of the child(ren) and has had physical custody of the 
child(ren) for at least 10 days in any 30-day period within the last 12 months. Detail the time 
periods during the past 12 months when the child(ren) have resided with the Petitioner: 
______________________________________________________________________________ 
_____________________________________________________________________________ 
______________________________________________________________________________. 
 
10. Petitioner does not have signed, written documentation from a parent which is sufficient to 
enable the Petitioner to do all of the things necessary to care for the child(ren). 
 
11. {If applicable} Describe the type of documents, if any, provided by the parent or parents which 
enables the Petitioner to act on behalf of the child(ren): ________________________________ 
______________________________________________________________________________. 
These documents are attached to this Petition as Exhibit ________. 
 
12. Petitioner is unable to obtain or undertake the following services or actions without an order of 
custody: 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________. 
 
13. The Consents of ______Father and/or _________ Mother is/are attached to the Petition. 
OR 
[If applicable] The Consent of the _________________ is not attached because that parent is 
deceased. A certified copy of the  proof of death is attached. 
 
14. Petitioner requests concurrent custody be granted for the following period of 
time:________________________________________________________________________.   
The reasons that support this request are: ___________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________. 
 
Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family 
 (04/11) 
 
- 16 - 
15. It is in the best interests of the child(ren) that the Petitioner have concurrent custody of the 
child(ren) for the following reasons: ________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
_____________________________________________________________________________. 
 
16. ORDER OF PROTECTION 
___ 
Petitioner IS NOT aware of any temporary or permanent order for protection entered 
on behalf of or against either parent, the Petitioner, or the child(ren) in Florida or any 
other jurisdiction. 
 
OR 
___ 
Petitioner IS aware of the following temporary or permanent orders for protection 
entered on behalf of or against either parent, the Petitioner, or the child(ren) in Florida 
or any other jurisdiction. The court entering the order and the case number is: _______ 
________________________________________________________________________ 
________________________________________________________________________ 
_______________________________________________________________________. 
 
17. TEMPORARY OR PERMANENT CHILD SUPPORT ORDERS 
___ 
Petitioner IS NOT aware of any temporary or permanent orders for child support for the 
minor child(ren). 
 
OR 
___ 
Petitioner IS aware of the following temporary or permanent order for child support for 
the minor child(ren).  The court entering the order and the case number is:__________ 
 
_______________________________________________________________________ 
 
_______________________________________________________________________ 
 
_______________________________________________________________________. 
 
18. CHILD SUPPORT (If Petitioner is seeking child support)  [Choose one only]  
(You must have proof of service upon or waiver of process by the parent(s) or a Waiver of 
Service of Process and Consent for the court to consider an award for child support) 
 
___ 
Petitioner requests the court to order the parents to pay child support. 
___ 
Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing 
child support obligation to the Petitioner. 
___ 
Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing 
child support obligation to the Petitioner, and to award the Petitioner child support 
arrearages. 
 
19. Petitioner ____ requests _____ does not request that the court establish reasonable visitation 
or a time-sharing schedule with the parents. 
 
20. Other _______________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
_____________________________________________________________________________ 
Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family 
 (04/11) 
 
- 17 - 
 
WHEREFORE, Petitioner requests that this Court grant the Petitioner concurrent custody of the 
child(ren) subject to this proceeding; award the Petitioner other relief as requested; and award any 
other relief that the Court deems necessary. 
 
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 Code: ________________________ 
 
 
 
 
 
 
Telephone Number: _________________________ 
 
 
 
 
 
 
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: [fill in 
all blanks] 
I, {full legal name and trade name of nonlawyer} ________________________________________ 
a nonlawyer, whose address is {street} ________________________________________________,  
{city} _______________________, {state} ___________, {phone} _______________________, helped 
{name} ______________________________________________ who is the Petitioner, fill out this form. 
 
 
 
 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(c), Waiver of Service of Process and 
Consent for Temporary Custody By Extended Family (04/11) 
 
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW 
FORM, 12.970(c), WAIVER OF SERVICE OF PROCESS AND CONSENT FOR 
TEMPORARY CUSTODY BY EXTENDED FAMILY (04/11) 
 
 
This form is to be completed and signed by a parent who agrees to grant temporary custody of a minor 
child or child(ren) to an extended family member and agrees to waive service of process.  Service of 
process occurs when a summons and a copy of the petition (or other pleading) that has been filed with 
the court are delivered by a deputy or private process server. 
 
An Extended Family Member is: 
A relative of a minor child within the third degree by blood or marriage to the parent;  
OR 
The stepparent of a minor child if the stepparent is currently married to the parent of the child and is 
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. 
 
 
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 file the original with the clerk of the circuit court in 
the county where the Petition for Temporary Custody by Extended Family, Florida Supreme Court 
Approved Family Law Form 12.970(a) 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 a Disclosure from Nonlawyer, Florida Family Law Rules 
of Procedure Form 12.900(a), before he or she helps you.  A nonlawyer helping you fill out these forms  
must also 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. 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(c), Waiver of Service of Process and Consent for 
Temporary Custody By Extended Family (04/11) 
 
- 19 - 
IN THE CIRCUIT COURT OF THE _______________ JUDICIAL CIRCUIT, 
IN AND FOR _______________________________ COUNTY, FLORIDA 
 
 
 
 
 
 
 
 
Case No: _______________________ 
 
 
 
 
 
 
 
Division: _______________________ 
 
__________________________________, 
 
 
 
Petitioner, 
and 
__________________________________, 
 
 
 
Respondent/Mother, 
 
__________________________________, 
 
 
 
Respondent/Father. 
 
 
WAIVER OF SERVICE OF PROCESS AND CONSENT FOR TEMPORARY CUSTODY BY EXTENDED 
FAMILY 
 
 
 
I, _____________________________________________, the legal _____ Mother ____ Father of  
{child(ren)’s name)s)} _____________________________________________, having received a copy of 
the Petition for Temporary Custody by Extended Family filed herein and waived service of process, freely 
and voluntarily consent to the Petition filed by: {Petitioner’s Name} __________________________. 
I realize that by signing this document, I am consenting to the Petitioner having temporary legal custody 
of the minor child(ren) and that such temporary custody is in the best interest of the child(ren).  Upon 
entry of an Order, the Petitioner shall be able to: 
1. Consent to all necessary and reasonable medical and dental care for the child(ren), including 
nonemergency surgery and psychiatric care; 
2. 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. 
3. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be tested or 
placed in special school programs, including exceptional education; and 
4. Do all other things necessary for the care of the child(ren). 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(c), Waiver of Service of Process and Consent for 
Temporary Custody By Extended Family (04/11) 
 
- 20 - 
I realize that the custody of my child(ren) by the Petitioner is temporary and that I may, at any time, 
petition the court to return legal custody to me. 
 
Dated: __________________ 
 
 
 
 
 
 
_________________________________________ 
 
 
 
 
 
 
Signature of Parent 
 
 
 
 
 
 
Printed Name: _____________________________ 
 
 
 
 
 
 
Address: __________________________________ 
 
 
 
 
 
 
City, State, Zip Code: ________________________ 
 
 
 
 
 
 
Telephone Number: _________________________ 
 
 
 
 
 
 
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: [fill in 
all blanks] 
I, {full legal name and trade name of nonlawyer} ________________________________________ 
a nonlawyer, whose address is {street} ________________________________________________,  
{city} ______________________________, {state} ___________, {phone} ___________________,  
helped {name} ______________________________________who is a Respondent, fill out this form. 
 
 
 
Instructions for Florida Supreme Court Approved Family Law Form 12.970(d), Waiver of Service of Process and 
Consent for Concurrent Custody By Extended Family (04/11) 
 
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW 
FORM, 12.970(d), WAIVER OF SERVICE OF PROCESS AND CONSENT FOR 
CONCURRENT CUSTODY BY EXTENDED FAMILY (04/11) 
 
 
This form is to be completed and signed by a parent who agrees to grant concurrent custody of a minor 
child or child(ren) to an extended family member and who agrees to waive service of process.  Service 
of process occurs when a summons and a copy of the petition (or other pleading) that has been filed 
with the court are delivered by a deputy or private process server.  “Concurrent custody” means that an 
eligible extended family member is awarded custodial rights to care for a child or children concurrently 
with the child(ren)’s parent or parents. 
 
An Extended Family Member is: 
A relative of a minor child within the third degree by blood or marriage to the parent;  
OR 
The stepparent of a minor child if the stepparent is currently married to the parent of the child and is 
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. 
 
 
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 file the original with the clerk of the circuit court in 
the county where the Petition for Concurrent Custody by Extended Family, Florida Supreme Court 
Approved Family Law Form 12.970(b) 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 a Disclosure from Nonlawyer, Florida Family Law Rules 
of Procedure Form 12.900(a), before he or she helps you.  A nonlawyer helping you fill out these forms 
must also 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. 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(d), Waiver of Service of Process and Consent for 
Concurrent Custody By Extended Family (04/11) 
 
- 22 - 
IN THE CIRCUIT COURT OF THE _______________  JUDICIAL CIRCUIT, 
IN AND FOR _______________________________ COUNTY, FLORIDA 
 
 
 
 
 
 
 
 
Case No: _______________________ 
 
 
 
 
 
 
 
Division: _______________________ 
 
__________________________________, 
 
 
 
Petitioner, 
and 
__________________________________, 
 
 
 
Respondent/Mother, 
 
__________________________________, 
 
 
 
Respondent/Father. 
 
 
WAIVER OF SERVICE OF PROCESS AND CONSENT FOR CONCURRENT CUSTODY BY EXTENDED 
FAMILY 
 
 
 
I, ____________________________________________, the legal _____ Mother ____ Father of 
 {child(ren)’s name(s)} _____________________________________, having received a copy of the 
Petition for Concurrent Custody by Extended Family filed herein and waived service of process,  freely 
and voluntarily consent to the Petition filed by {Petitioner’s Name} ______________________________. 
I realize that by signing this document, I am consenting to the Petitioner having temporary concurrent 
custody of the minor child(ren) and that such concurrent custody is in the best interest of the child(ren).  
Upon entry of an Order, the Petitioner shall be able to: 
1. Consent to all necessary and reasonable medical and dental care for the child(ren), including 
nonemergency surgery and psychiatric care; 
2. 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. 
3. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be tested or 
placed in special school programs, including exceptional education; and 
4. Do all other things necessary for the care of the child(ren). 
 
Florida Supreme Court Approved Family Law Form 12.970(d), Waiver of Service of Process and Consent for 
Concurrent Custody By Extended Family (04/11) 
 
- 23 - 
 
 
I realize that the concurrent custody of my child(ren) by the Petitioner is temporary and that I may, at 
any time, petition the court to return legal custody to me. 
 
Dated: _____________________________ 
 
 
 
 
 
 
 
_________________________________________ 
 
 
 
 
 
 
Signature of Parent 
 
 
 
 
 
 
Printed Name: _____________________________ 
 
 
 
 
 
 
Address: __________________________________ 
 
 
 
 
 
 
City, State, Zip Code: ________________________ 
 
 
 
 
 
 
Telephone Number: _________________________ 
 
 
 
 
 
 
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: [fill in 
all blanks] 
I, {full legal name and trade name of nonlawyer} _________________________________________ 
a nonlawyer, whose address is {street} ________________________________________________,  
{city} _______________________, {state} ___________, {phone} ____________________________, 
helped {name} __________________________________ who is a Respondent, fill out this form. 
 
 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
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IN THE CIRCUIT COURT OF THE _________________________ JUDICIAL CIRCUIT 
IN AND FOR __________________________ COUNTY, FLORIDA 
 
 
 
 
 
 
 
 
 
Case No: ______________________ 
 
 
 
 
 
 
 
 
Division: ______________________ 
 
__________________________________, 
 
 
 
Petitioner, 
and 
__________________________________, 
 
 
 
Respondent/Mother 
 
__________________________________, 
 
 
 
Respondent/Father. 
 
ORDER GRANTING PETITION FOR  
TEMPORARY CUSTODY BY EXTENDED FAMILY 
 
 
This case came before this Court for a hearing on a Petition for Temporary Custody by 
Extended Family.  The Court, having reviewed the file and heard the testimony, makes these 
findings of fact and reaches these conclusions of law: 
 
SECTION I. FINDINGS: 
 
1. The Court has jurisdiction over the subject matter and the parties. 
 
2. The minor child(ren) at issue in this matter are: 
Name  
 
 
 
 
 
 
Date of Birth 
___________________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 
 
3. The Petitioner, {full legal name} _____________________________________ is the 
{extended family relationship}___________________________________________ of 
the child(ren). 
 
4. The Mother {full legal name} _________________________________ of the child(ren):  
(Choose one only) 
___ 
Filed a Waiver and Consent 
___ 
Was served with the petition and failed to file an Answer 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
- 25 - 
___      Is deceased as evidenced by: __________________________________________ 
___ 
Objected to the petition.  Based upon clear and convincing evidence, the Court 
finds that the Mother is unfit to provide for the care and control of the 
child(ren).  Specifically, the Mother has abused, abandoned, or neglected the 
child(ren) as defined in Chapter 39, Florida Statutes.   It is in the best interest of 
the child(ren) that the Petitioner have temporary custody because: {facts in 
support of finding} __________________________________________________ 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
_________________________________________________________________. 
 
5. The Father {full legal name} _________________________________ of the child(ren):  
(Choose one only) 
___ 
Filed a Waiver and Consent 
___ 
Was served with the petition and failed to file an Answer 
___      Is deceased as evidenced by:  __________________________________________ 
___ 
Objected to the petition.  Based upon clear and convincing evidence, the Court 
finds that the Father is unfit to provide for the care and control of the child(ren).  
Specifically, the Father has abused, abandoned, or neglected the child(ren) as 
defined in Chapter 39, Florida Statutes.   It is in the best interest of the child(ren) 
that the Petitioner have temporary custody because: {facts in support of finding} 
_________________________________________________________________ 
 
_________________________________________________________________ 
 
_________________________________________________________________ 
 
_________________________________________________________________ 
 
_________________________________________________________________. 
 
6. It is in the best interest of the child(ren) for the Petitioner to have temporary custody. 
 
SECTION II: TEMPORARY CUSTODY 
 
1. The Petitioner, ___________________________________, is granted temporary 
custody of the minor child(ren). 
 
2. The Petitioner shall have all the rights and responsibilities of a legal parent. 
 
3. The Petitioner is authorized to make all reasonable and necessary decisions for the 
minor child(ren), including but not limited to: 
a) Consent to all necessary and reasonable medical and dental care for the child(ren), 
including nonemergency surgery and psychiatric care; 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
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b) 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: 
i. 
Medical, Dental, and psychiatric records; 
ii. 
Birth certificates and other records; and 
iii. 
Educational records. 
 
4. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be 
tested or placed in special school programs, including exceptional education; and 
 
5. Do all other things necessary for the care of the child(ren). 
 
SECTION III. TEMPORARY TIME-SHARING WITH MINOR CHILD(REN) 
 
The parent(s) shall have: (Choose one only) 
1. ___ reasonable time-sharing with the minor child(ren) as agreed to by the parties, 
subject to the following limitations: __________________________________________ 
_______________________________________________________________________. 
 
2. ___ the following specified time-sharing schedule: {specify days and times} _______ 
______________________________________________________________________. 
Mother’s Temporary Time-Sharing Schedule. 
________________________________________________________________________ 
________________________________________________________________________ 
_______________________________________________________________________. 
Father’s Temporary Time-Sharing Schedule. 
_______________________________________________________________________ 
_______________________________________________________________________ 
_______________________________________________________________________. 
 
3. ___ Time-Sharing in accordance with the temporary Parenting Plan attached as  
        Exhibit ___. 
 
4. ___ (   ) Mother (   ) Father shall have No Contact with the minor child(ren) until further 
order of the Court, due to existing conditions that are detrimental to the welfare of the 
minor child(ren): {explain} _________________________________________________ 
_______________________________________________________________________ 
_______________________________________________________________________. 
 
SECTION IV. CHILD SUPPORT 
 
1. The Petitioner ____ did  ____ did not request the establishment of child support. 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
- 27 - 
 
2. ___ If child support is requested, the parents have received personal or substituted 
service of process, the petition requests an order for support of the child(ren), and there 
is evidence of the parents’ ability to pay the support ordered.  The(   ) Mother (   ) Father 
has the present ability to pay child support.  
(Choose one only)  
___ The amounts in the Child Support Guidelines Worksheet, Florida Family Law Rules 
of Procedure Form 12.902(e) filed by the (   ) Mother (   ) Father are correct; 
OR 
___ The Court makes the following findings:  The Mother’s net monthly income is 
$_______________, (Child Support Guidelines ___%). The Father’s net monthly income 
is $____________________, (Child Support Guidelines ____%)  Monthly child care costs 
are $_________________.  Monthly health/dental insurance costs are $_____________. 
OR 
 
___ The (   ) Mother (   ) Father is currently ordered to pay child support to the other 
parent in the amount of $_____________ per ________________ as established in the 
case of {style of case and number}  ___________________________________________ 
 
_______________________________________________________________________. 
 
(    ) All of the child support or (   ) a portion of the child support in the amount of 
$_________ shall be redirected to the Petitioner. 
 
3. Amount 
a) Father’s Obligation  
      The Father shall be obligated to pay child support in the amount of $___________ 
for the______ children {total number of parties’ minor or dependent children} 
commencing ____________________ {month, day, year} and terminating 
______________________ {month, day, year}. 
 
      Upon the termination of the obligation of child support for one of the parties’ 
children, child support in the amount of $__________ for the remaining_______ 
children {total number of remaining children} shall be paid commencing 
________________ {month, day, year} and terminating _______________________ 
{month, day, year}. 
 
     {Insert paragraph for the child support obligation, including the amount, 
commencement, and termination dates, for the remaining minor or dependent 
children, which shall be payable as the obligation for each child ceases.}       
   
      The Father shall pay child support until all minor or dependent children: reach the 
age of 18; become emancipated, marry, join the armed services, die, or become self-
supporting; or until further order of the court or agreement of the parties.  The child 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
- 28 - 
support obligation shall continue beyond the age of 18 and until high school 
graduation for any child who is dependent in fact, between the ages of 18 and 19, 
and is still in high school, performing in good faith with a reasonable expectation of 
graduation before the age of 19. 
 
 
If the child support ordered deviates from the guidelines more than 5%, the factual 
findings which support that deviation are: __________________________________ 
 
_____________________________________________________________________ 
 
____________________________________________________________________. 
 
      Child support shall be payable (   ) at least once a month and in accordance with 
Father’s employer’s payroll cycle, or (    ) other {explain}_______________________ 
      _____________________________________________________________________. 
 
b)  Mother’s Obligation 
The Mother shall be obligated to pay child support in the amount of $____________ 
for the ______ children {total number of parties’ minor or dependent children} 
commencing __________________________ {month, day, year} and terminating 
______________________ {month, day, year}. 
 
Upon the termination of the obligation of child support for one of the parties’ 
children, child support in the amount of $___________ for the remaining ______ 
children {total number of remaining children} shall be paid commencing 
_______________ {month, day, year} and terminating ________________________ 
{month, day, year}. 
 
{Insert paragraph for the child support obligation, including the amount, 
commencement, and termination dates, for the remaining minor or dependent 
children which shall be payable as the obligation for each child ceases.} 
 
The Mother shall pay child support until all of the minor or dependent children:  
reach the age of 18; become emancipated, marry, join the armed services, die, or 
become self-supporting; or until further order of the court or agreement of the 
parties.  The child support obligation shall continue beyond the age of 18 and until 
high school graduation for any child who is dependent in fact, between the ages of 
18 and 19, and is still in high school, performing in good faith with a reasonable 
expectation of graduation before the age of 19. 
 
If the child support ordered deviates from the guidelines more than 5%, the factual 
findings which support that deviation are:  __________________________________ 
_____________________________________________________________________ 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
- 29 - 
____________________________________________________________________. 
 
Child support shall be payable (   ) at least once a month and in accordance with the 
Mother’s employer’s payroll cycle, or (   ) other {explain} ______________________ 
____________________________________________________________________. 
 
4. Arrearages/Retroactive Child Support 
a) The (  ) Mother (  ) Father owes child support arrearages in the amount of 
$_________ as of {date} ________________ to the other parent. The child support 
arrearages shall be repaid in the amount of $_______ per month, payable (   ) in 
accordance with the employer’s payroll cycle, and in any event at least once per 
month (   ) other {explain} _______________________________________________ 
commencing {date} _____________________, until paid in full including statutory 
interest. 
 
b) The (   ) Mother (   ) Father owes retroactive child support in the amount of 
$_________ as of {date} ________________ to the Petitioner. The retroactive child 
support  shall be repaid in the amount of $_______ per month, payable (   ) in 
accordance with the employer’s payroll cycle, and in any event at least once per 
month (   )other {explain} ________________________________________________ 
_____________________________________________________________________ 
commencing {date} ______________________, until paid in full including statutory 
interest. 
 
5. Insurance 
 
(Choose all that apply) 
a) (   ) Mother (   ) Father shall be required to maintain  (   ) health and/or (   ) dental 
insurance for the parties’ minor child(ren), so long as reasonable in cost and 
accessible to the child(ren).  The party providing insurance shall be required to 
convey insurance cards demonstrating said coverage to the Petitioner and other 
parent. 
OR 
(   ) health and/or (   ) dental insurance is either not reasonable in cost or accessible 
to the child(ren) at this time. 
 
b) ___ Reasonable and necessary uninsured medical/dental/prescription drug costs for 
the minor child(ren) shall be assessed as follows: 
(   ) Shared equally by both parents. 
(   ) Prorated according to the child support guidelines percentages. 
(   ) Other {explain} ______________________________________________ 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
- 30 - 
As to these uninsured medical/dental/prescription drug expenses, the party who 
incurs the expense shall submit a request for reimbursement to the parent or 
parents within 30 days, and the parent or parents, within 30 days of receipt, shall 
submit the applicable reimbursement for that expense. 
 
SECTION V. METHOD OF PAYMENT 
 
The parent(s) shall pay court-ordered child support and arrearages, if any, as follows: 
1. State Disbursement Unit 
(Choose if applies) 
a) ___Parent(s) shall pay court-ordered support directly to the State Disbursement Unit 
along with the deposit service charge. 
 
b) ___ The Petitioner and the Parent(s) have requested and the Court finds that it is in 
the best interest of the child(ren) that support payments need not be directed 
through the State Disbursement Unit at this time; however, any party may 
subsequently apply, pursuant to section 61.13(1)(d)(3), Florida Statutes, to require 
payment through the State Disbursement Unit. 
 
2. Income Deduction 
(If applicable) 
a) ___ Immediate. (   ) Mother (   ) Father shall pay through income deduction, 
pursuant to a separate Income Deduction Order which shall be effective 
immediately.  Payor is individually responsible for paying this support obligation 
until all of said support is deducted from his/her income.  Until support payments 
are deducted, the Payor is responsible for making timely payments directly to the 
State Disbursement Unit or the Petitioner as previously set forth in this Order. 
b) ___ Deferred. Income deduction is ordered this day, but it shall not be effective until 
a delinquency of $_____________, or, if not specified, an amount equal to one 
month’s obligation occurs.  Income deduction is not being implemented 
immediately based on the following findings:  Income deduction is not in the best 
interests of the child(ren) because: {explain}  ________________________________ 
_____________________________________________________________________ 
____________________________________________________________________. 
AND 
There is proof of timely payment of a previously ordered obligation without an 
Income Deduction Order, 
AND 
(   ) there is an agreement by the Payor(s) to advise the State Disbursement Unit of 
any change in Payor(s) or health insurance OR (   ) there is a signed, written 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
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agreement providing an alternative arrangement between the Petitioner and 
Payor(s). 
 
3. Bonus/one-time payments. 
[Choose one only] 
 
(   ) All (   ) __________% (   ) No income paid in the form of a bonus or other similar one-
time payment, up to the amount of any arrearage or the remaining balance thereof 
owed pursuant to this order, shall be forwarded to the Petitioner pursuant to the 
payment method prescribed above. 
 
4. Other provisions relating to method of payment: _______________________________ 
_______________________________________________________________________. 
 
SECTION VI.  ATTORNEY FEES, COSTS, AND SUIT MONEY 
(Choose one only) 
 
1. ___ (   ) Petitioner’s (    )Respondents’ request(s) for attorney fees, costs, and suit money 
is (are) denied because ____________________________________________________ 
_______________________________________________________________________. 
 
2. ___ The Court finds there is a need for and ability to pay attorney fees, costs, and suit 
money. (   ) Petitioner (   ) Respondent(s) is (are) ordered to pay the other party 
$________ in attorney fees, and $ ______ in costs.  The Court further finds that the 
attorney fees are awarded based on the reasonable rate of $________________ per 
hour and ________________ reasonable hours.  Other provisions relating to attorney 
fees, costs, and suit money are as follows: _____________________________________ 
_______________________________________________________________________. 
 
SECTION VII. OTHER PROVISIONS 
 
1. Other Provisions   ________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
_______________________________________________________________________. 
 
2. The Court reserves jurisdiction to modify and enforce this Order for Temporary Custody. 
 
 
Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by 
Extended Family (04/11) 
 
- 32 - 
 
 
DONE AND ORDERED in ______________________, Florida on {date} __________________ 
 
 
 
 
 
 
 
 
 
 
_____________________________ 
 
 
 
 
 
 
 
CIRCUIT JUDGE 
 
A copy of this Order for Temporary Custody was:  [Choose one only]  
(   ) mailed (   ) faxed and mailed (   ) hand delivered to the parties listed below on  
{date} _______________ by ________________________________{clerk of court or designee}. 
 
Petitioner (or his or her attorney) 
Respondents (or his or her attorney) 
State Disbursement Unit 
Other _________________________________ 
 
 
 
 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
- 33 - 
IN THE CIRCUIT COURT OF THE _________________________ JUDICIAL CIRCUIT 
IN AND FOR __________________________ COUNTY, FLORIDA 
 
 
 
 
 
 
 
 
 
Case No: ______________________ 
 
 
 
 
 
 
 
 
Division: ______________________ 
 
__________________________________, 
Petitioner, 
and 
__________________________________, 
 
 
 
Respondent/Father 
 
__________________________________, 
 
 
 
Respondent/Mother. 
 
 
ORDER GRANTING PETITION FOR  
CONCURRENT CUSTODY BY EXTENDED FAMILY 
 
 
This case came before this Court for a hearing on a Petition for Concurrent Custody by 
Extended Family.  The Court, having reviewed the file and heard the testimony, makes these 
findings of fact and reaches these conclusions of law: 
 
SECTION I. FINDINGS: 
 
1. The Court has jurisdiction over the subject matter and the parties. 
 
2. The minor child(ren) at issue in this matter are: 
Name  
 
 
 
 
 
 
Date of Birth 
___________________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 
 
3. The Petitioner, {full legal name} _____________________________________ is the 
{extended family relationship}___________________________________________ of 
the child(ren). 
 
4. The Petitioner currently has physical custody of the child(ren) and has had physical 
custody of the child(ren) for at least 10 days in any 30-day period within the last 12 
months. 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
- 34 - 
 
5. The Petitioner does not have signed, written documentation from the parent(s) which is 
sufficient to enable the custodian to do all the things necessary to care for the child(ren) 
which are available to custodians who have an order for temporary custody by extended 
family. 
 
6. The Mother {full legal name} _________________________________ of the child(ren):  
(choose one only) 
___ 
Filed a Waiver and Consent 
___ 
Was served with the petition and failed to file an Answer 
            ___      Is deceased as evidenced by: _______________________________________ 
 
7. The Father {full legal name} _________________________________ of the child(ren):  
(choose one only) 
___ 
Filed a Waiver and Consent 
___ 
Was served with the petition and failed to file an Answer 
___      Is deceased as evidenced by: _______________________________________ 
 
8. It is in the best interest of the child(ren) for the Petitioner to have concurrent custody. 
 
SECTION II: CONCURRENT CUSTODY 
 
1. The Petitioner,___________________________________________________, is granted 
concurrent custody of the minor child(ren). 
 
2. The Petitioner shall have all the concurrent rights and responsibilities of a legal parent. 
 
3. The Petitioner is authorized to make all reasonable and necessary decisions for the 
minor child(ren), including but not limited to: 
a) Consent to all necessary and reasonable medical and dental care for the 
child(ren), including nonemergency surgery and psychiatric care; 
b) 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: 
i. 
Medical, Dental, and psychiatric records; 
ii. 
Birth certificates and other records; and 
iii. 
Educational records. 
 
4. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be 
tested or placed in special school programs, including exceptional education; and 
 
5. Do all other things necessary for the care of the child(ren). 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
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SECTION III. CHILD SUPPORT 
 
1. The Petitioner ____ did  ____ did not request the establishment of child support. 
 
2. ___ If child support is requested, the parents have received personal or substituted 
service of process, the petition requests an order for support of the child(ren), and there 
is evidence of the parents’ ability to pay the support ordered.  The (   )Mother (   ) Father 
has the present ability to pay child support  
(Choose one only)  
___ The amounts in the Child Support Guidelines Worksheet, Florida Family Law Rules 
of Procedure Form 12.902(e) filed by the (   )Mother (   ) Father are correct; 
OR 
___ The Court makes the following findings:  The Mother’s net monthly income is 
$_______________, (Child Support Guidelines ___%). The Father’s net monthly income 
is $____________________, (Child Support Guidelines ____%)  Monthly child care costs 
are $_________________.  Monthly health/dental insurance costs are $_____________. 
OR 
 
___ The (   ) Mother (   ) Father is currently ordered to pay child support to the other 
parent in the amount of $_____________ per ________________ as established in the 
case of (style of case and number}  _________________________________________ 
 
_____________________________________________________________________. 
 
(    ) All of the child support or (   ) a portion of the child support in the amount of 
$_________ shall be redirected to the Petitioner. 
 
3. Amount 
      a) Father’s Obligation  
 
The Father shall be obligated to pay child support in the amount of $__________ for the 
_______children {total number of parties’ minor or dependent children} commencing 
_________________ {month, day, year} and terminating ________________________ 
{month, day, year}. 
 
      Upon the termination of child support for one of the parties’ children, child support in 
the amount of $_____________ for the remaining _________ children {total number of 
remaining children} shall be paid commencing __________________ {month, day, year} 
and terminating _________________________ {month, day, year}. 
 
     {Insert paragraph for the child support obligation, including the amount, 
commencement, and termination dates, for the remaining minor or dependent 
children, which shall be payable as the obligation for each child ceases.} 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
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      The Father shall pay child support until all of the minor or dependent children:  reach the 
age of 18, become emancipated, marry, join the armed services, die, or become self-
supporting; or until further order of the court or agreement of the parties.  The child 
support obligation shall continue beyond the age of 18 and until high school graduation 
for any child who is dependent in fact, between the ages of 18 and 19, and is still in high 
school, performing in good faith with a reasonable expectation of graduation before the 
age of 19. 
 
 
 
 
 
If the child support ordered deviates from the guidelines more than 5%, the factual 
findings which support that deviation are: ____________________________________ 
 
_______________________________________________________________________ 
 
_______________________________________________________________________. 
 
 
Child support shall be payable (  ) at least once a month and in accordance with the 
Father’s employer’s payroll cycle, or (  ) other {explain}___________________________ 
 
________________________________________________________________________ 
 
 
b) Mother’s Obligation 
The Mother shall be obligated to pay child support in the amount of $____________ for 
the ________children {total number of parties’ minor or dependent children} 
commencing {month, day, year} and terminating __________________ {month, day, 
year}. 
 
Upon the termination of the obligation of child support for one of the parties’ children, 
child support in the amount of $__________ for the remaining ______ children {total 
number of remaining children} shall be paid commencing _____________________ 
{month, day, year} and terminating ________________________ month, day, year}. 
 
{Insert paragraph for the child support obligation, including the amount, 
commencement, and termination dates, for the remaining minor or dependent 
children, which shall be payable as the obligation for each child ceases.} 
 
The Mother shall pay child support until all of the minor or dependent children: reach 
the age of 18; become emancipated, marry, join the armed services, die, or become self-
supporting; or until further order of the court or agreement of the parties.  The child 
support obligation shall continue beyond the age of 18 and until high school graduation 
for any child who is dependent in fact, between the ages of 18 and 19, and is still in high 
school, performing in good faith with a reasonable expectation of graduation before the 
age of 19. 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
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If the child support ordered deviates from the guidelines more than 5%, the factual 
findings which support that deviation are:______________________________________ 
________________________________________________________________________ 
_______________________________________________________________________. 
 
Child support shall be payable (   ) at least once a month and in accordance with the 
Mother’s employer’s payroll cycle, or (   ) other {explain}__________________________ 
_______________________________________________________________________.  
 
 
4. Arrearages/Retroactive Child Support 
a) The (   )Mother (   ) Father owes child support arrearages in the amount of 
$_________ as of {date} ________________ to the other parent. The child 
support arrearages shall be repaid in the amount of $_______ per month, 
payable (   ) in accordance with the employer’s payroll cycle, and in any event at 
least once per month (   )other {explain} ________________________________ 
__________________________________________________________________ 
commencing {date} ______________________, until paid in full including 
statutory interest. 
 
b) The (   ) Mother (   ) Father owes retroactive child support in the amount of 
$_________ as of {date} ________________ to the Petitioner. The retroactive 
child support  shall be repaid in the amount of $_______ per month, payable (   ) 
in accordance with the employer’s payroll cycle, and in any event at least once 
per month (   )other {explain} __________________________________________ 
__________________________________________________________________ 
commencing {date} ______________________, until paid in full including 
statutory interest. 
 
5. Insurance 
 
(Choose all that apply) 
a) (   ) Mother (   ) Father shall be required to maintain  (   ) health and/or (   ) dental 
insurance for the parties’ minor child(ren), so long as reasonable in cost and 
accessible to the child(ren).  The party providing insurance shall be required to 
convey insurance cards demonstrating said coverage to the Petitioner and other 
parent. 
OR 
(   ) health and/or (   ) dental insurance is either not reasonable in cost or 
accessible to the child(ren) at this time. 
 
b) ___ Reasonable and necessary uninsured medical/dental/prescription drug costs 
for the minor child(ren) shall be assessed as follows: 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
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(   ) Shared equally by both parents. 
(   ) Prorated according to the child support guidelines percentages. 
(   ) Other {explain} ______________________________________________ 
 
As to these uninsured medical/dental/prescription drug expenses, the party who 
incurs the expense shall submit a request for reimbursement to the parent or 
parents within 30 days, and the parent or parents, within 30 days of receipt, shall 
submit the applicable reimbursement for that expense. 
 
SECTION IV. METHOD OF PAYMENT 
 
The parent(s) shall pay court-ordered child support and arrearages, if any, as follows: 
1. State Disbursement Unit 
(Choose if applies) 
a) ___Parent(s) shall pay court-ordered support directly to the State Disbursement 
Unit along with the deposit service charge. 
 
b) ___ The Petitioner and the Parents have requested and the court finds that it is 
in the best interest of the child(ren) that support payments need not be directed 
through the State Disbursement Unit at this time; however, any party may 
subsequently apply, pursuant to section 61.13(1)(d)(3), Florida Statutes, to 
require payment through the State Disbursement Unit. 
 
2. Income Deduction 
(If applies) 
a) ___ Immediate. (   ) Mother (   ) Father shall pay through income deduction, 
pursuant to a separate Income Deduction Order which shall be effective 
immediately.  Payor is individually responsible for paying this support obligation 
until all of said support is deducted from his/her income.  Until support 
payments are deducted, the Payor is responsible for making timely payments 
directly to the State Disbursement Unit or the Petitioner as previously set forth 
in this Order. 
b) ___ Deferred. Income deduction is ordered this day, but it shall not be effective 
until a delinquency of $_____________, or, if not specified, an amount equal to 
one month’s obligation occurs.  Income deduction is not being implemented 
immediately based on the following findings:  Income deduction is not in the 
best interests of the child(ren) because: {explain} _________________________ 
_______________________________________________________________ 
_______________________________________________________________. 
 
 
AND 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
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There is proof of timely payment of a previously ordered obligation without an 
Income Deduction Order, 
AND 
(   ) there is an agreement by the Payor(s) to advise the State Disbursement Unit 
of any change in Payor(s) or health insurance OR (   ) there is a signed, written 
agreement providing an alternative arrangement between the Petitioner and 
Payor(s). 
 
3. Bonus/one-time payments. 
[Choose one only] 
(   ) All (   ) __________% (   ) No income paid in the form of a bonus or other similar one-
time payment, up to the amount of any arrearage or the remaining balance thereof 
owed pursuant to this order, shall be forwarded to the Petitioner pursuant to the 
payment method prescribed above. 
 
4. Other provisions relating to method of payment: _______________________________ 
________________________________________________________________________ 
 
SECTION V.  ATTORNEY FEES, COSTS, AND SUIT MONEY 
(Choose one only) 
 
1. ___ (   ) Petitioner’s (   ) Respondents’ request(s) for attorney fees, costs, and suit money 
is (are) denied because ____________________________________________________ 
_____________________________________________________________________. 
2. ___ The Court finds there is a need for and ability to pay attorney fees, costs, and suit 
money. (   ) Petitioner (   ) Respondent(s) is (are) ordered to pay the other party 
$________ in attorney fees, and $ ______ in costs.  The Court further finds that the 
attorney fees are awarded based on the reasonable rate of $________________ per 
hour and ________________ reasonable hours.  Other provisions relating to attorney 
fees, costs, and suit money are as follows: _____________________________________ 
_______________________________________________________________________. 
 
SECTION VI. OTHER PROVISIONS 
 
1. Other Provisions _________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
 
2. The Court reserves jurisdiction to modify and enforce this Order for Concurrent Custody. 
 
 
 
Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by 
Extended Family (04/11) 
 
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3. The granting of concurrent custody does not affect the ability of the child(ren)’s parent 
or parents to obtain physical custody of the child(ren) at any time. 
 
 
DONE AND ORDERED in _____________________, Florida on {date} ____________________ 
 
 
 
 
 
 
 
 
 
 
_____________________________ 
 
 
 
 
 
 
 
CIRCUIT JUDGE 
 
A copy of this Order for Concurrent Custody was:  
[Choose one only] (   ) mailed (   ) faxed and mailed (   ) hand delivered to the parties listed 
below on {date}___________ by____________________________. {Clerk of court or designee} 
 
Petitioner (or his or her attorney) 
Respondents (or his or her attorney) 
State Disbursement Unit 
 
Other _________________________________