Florida Child Custody FormFlorida Child Custody FormFlorida Child Custody Form
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NINETEENTH
IN THE CIRCUIT COURT OF THE
JUDICIAL CIRCUIT,
ST LUCIE
IN AND FOR
COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and
,
Respondent.

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
AFFIDAVIT
I, {full legal name}
statements are true:

, being sworn, certify that the following

1. The number of minor child(ren) subject to this proceeding is
. The name, place of
birth, birth date, and sex of each child; the present address, periods of residence, and places
where each child has lived within the past five (5) years; and the name, present address, and
relationship to the child of each person with whom the child has lived during that time are:
THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD #
Child’s Full Legal Name:
Place of Birth:

Date of Birth:

1 :

Sex:

Child’s Residence for the past 5 years:
Dates
(From/To)

Address (including city and
state) where child lived

Name and present address of
person child lived with

Relationship
to child

/present*
___