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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.941(d), EMERGENCY VERIFIED MOTION FOR CHILD PICK-UP ORDER (03/09)
When should this form be used?
You may use this form to request that the court enter an order directing the sheriff or other law enforcement officer to take a minor child(ren) from the person who currently has physical possession of the child(ren) and deliver the child(ren) to your physical custody or possession. This form should only be used in an emergency by a person who has a pre-existing legal right to physical possession of a minor child. This means that you already have a court order awarding you legal custody of or time-sharing with the child(ren) OR you are the birth mother of one or more children born out of wedlock and no court order has addressed any other person=s parental rights. Before proceeding, you should read AGeneral Information for Self-Represented Litigants@ found at the beginning of these forms. This form should be typed or printed in black ink. This form presumes that you want the court to enter an ex parte order without giving the other side advance notice of the hearing. You should explain your reasons for why such an ex parte order should be entered in paragraph 7 of this form. After completing this form, you should sign the form before a notary public or deputy clerk. You should file the original, along with all of the other forms required, with the clerk of the circuit court in the county where the child(ren) is (are) physically located and keep a copy for your records. You should also ask the clerk to process your motion though their emergency procedures.

What should I do next?
If the court enters an order without advance notice to the other party, you should take a certified copy of the order to the sheriff=s office for further assistance. You must have this form and the court=s order served by personal service on the other party. You should read the court=s order carefully. The order may require the sheriff to place the child(ren) somewhere other than in your physical possession. Look for directions in the order that apply to you and note the time and place of the hearing scheduled in the order. You should go to the hearing with whatever evidence you have regarding your motion. If the court will not enter an order without advance notice to the other side, you should check with the clerk of court, judicial assistant, or family law intake staff for information on the local procedure for scheduling a hearing on your motion, unless the court sets a hearing in its order denying your request for an ex parte hearing. When you know the date and time of your hearing, you should file Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, and use personal service to notify the other party of your motion, the court=s order, if any, and the hearing.

Special notes...
With this form you must also file the following: Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d). A certified copy of the court order showing that you have legal custody of or time-sharing with

Instructions for Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order (03/09)

the child(ren), if any. OR A certified copy of the child(ren)=s birth certificate, if you are the birth mother of a child born out of wedlock and no court order addressing paternity exists. OR A certified copy of any judgment establishing paternity, time-sharing with or custody of the minor child(ren). Order... These family law forms contain an Order to Pick-Up Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.941(e), which the judge may use. You should check with the clerk, family law intake staff, or judicial assistant to see if you need to bring a blank order form with you to the hearing. If so, you should type or print the heading, including the circuit, county, case number, division, and the parties' names, and leave the rest blank for the judge to complete at your hearing. 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, 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 12.941(d), Emergency Verified Motion for Child Pick-Up Order (03/09)

IN THE CIRCUIT COURT OF THE IN AND FOR

JUDICIAL CIRCUIT, COUNTY, FLORIDA Case No.: Division:

, Petitioner, and , Respondent. EMERGENCY VERIFIED MOTION FOR CHILD PICK-UP ORDER I, {full legal name} certify that the following information is true: , being sworn,

1. This is a motion to enforce existing custody or time sharing rights (as an operation of law or court-ordered) regarding the following minor child(ren): Name Sex Birth Date Race Physical Description

2. Currently, the child(ren) subject to this motion is (are) in the physical possession of {full legal name}______________________________________________________________ ____________________________________ whose address or present physical location is: This individual's relationship to the minor child(ren) is:

3. I ( ) am ( ) am not married to the person named in paragraph 2. 4. Status of minor child(ren). I have a superior right to custody of or time-sharing with the minor child(ren) over the person named in paragraph 2 because: [all that apply]: a. ___ Custody or Time-Sharing has been established by a court. A final judgment or order awarding custody or time-sharing of the minor child(ren) was made on {date} ___________ in {name of court} {case number} . This order awarded custody of or specific time-sharing with the minor child(ren) to me. This final
Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order (03/09)

judgment or order applies to the following minor child(ren): {list name(s) of the child(ren) or write all} _____________________________________ _____________________________________________________________________ A certified copy of said final judgment or order is attached, has not been modified, and is still in effect. [ if applies] ( ) This order is an out-of-state court order which is entitled to full faith and credit enforcement under the Uniform Child Custody Jurisdiction and Enforcement Act and/or the federal Parental Kidnaping Prevention Act. b. ___ Custody or time-sharing is established as an operation of law. I am the birth mother of the minor child(ren) who was (were) born out of wedlock and there is no final judgment or order awarding custody of or time-sharing with the following minor child(ren): {list name(s) of the child(ren) or write all} ___________________ _____________________________________________________________________ _____________________________________________________________________ ___ Paternity has not been established. A certified copy of the minor child(ren)' birth certificate is attached and has not been amended. ___ Paternity has been established. A certified copy of the final judgment of paternity, which shows no award of custody or time-sharing was made, is attached. This order has not been changed and is still in effect. c. ___ Other: ______

5. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d), is filed with this motion. 6. Facts relating to the minor child(ren)=s current situation. [all that apply] a. ___ The person named in paragraph 2 wrongfully removed or wrongfully detained the minor child(ren) on {date} as follows: ____________________________________

_______ Please indicate here if you are attaching additional pages to continue these facts. b. ___ I believe that the minor child(ren) is (are) in immediate danger of harm or removal from this court's jurisdiction while with the person named in paragraph 2 based on the following: _________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ c. ___ The current location of the minor child(ren) is:
Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order (03/09)

( ) unknown ( ) believed to be at the following address(es) with the following people {list both the address and the people you believe will be there}:

7. Advance notice of this motion to the individual named in paragraph 2 should not be required because: _______________________________________________________________________

8. If needed, I can be contacted for notice of an emergency or expedited hearing at the following addresses/locations: ____________________________________________________________ Name of Contact Person: _________________________________________________________ Address: ______________________________________________________________________ Telephone number(s) where I (or my designee) can be reached: {give name of individual to call} ______________________________________________________________________________ Name of Contact Person: Address: Telephone number(s) where I (or my designee) can be reached: {give name of individual to call} ______________________________________________________________________________ 9. Attorneys' Fees, Costs, and Suit Monies. [if applicable] ___ I have filed this motion because of wrongful acts of the person listed in paragraph two above. I request that this Court award reasonable attorney's fees, costs, and suit monies as applicable or authorized under Florida law, the UCCJEA, and other legal authorities. WHEREFORE, I request an Emergency Order to Pick-Up Minor Child(ren), without advance notice, directing all sheriffs of the State of Florida or other authorized law enforcement officers in this state or any other state to pick up the previously named minor child(ren) and deliver them to my physical custody.

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order (03/09)

I understand that I am swearing or affirming under oath to the truthfulness of the claims made above 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 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 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, located at {street} , {city} , {state} , {phone} , helped {name} , who is the [ one only] petitioner or respondent, fill out this form.

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order (03/09)