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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.981(a)(5), INDIAN CHILD WELFARE ACT AFFIDAVIT When should this form be used? This form should be used in cases involving stepparent adoption of a child. This affidavit is required. This form should be typed or printed in black ink. After completing this form, you should sign the form before a notary public or deputy clerk. You should then file the original with the clerk of the circuit court in the county where the petition was filed and keep a copy for your records. What should I do next? A copy of this form must be mailed or hand delivered to the other party in your case, if it is not served on him or her with your initial papers. Where can I look for more information? Before proceeding, you should read "General Information for Self-Represented Litigants" found at the beginning of these forms. The words that are in "bold underline" in these instructions are defined there. Special notes... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, O` Florida Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit (03/04)

IN THE CIRCUIT COURT OF THE IN AND FOR

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JUDICIAL CIRCUIT, COUNTY, FLORIDA

Case No.: __________________________ Division: __________________________ IN THE MATTER OF THE ADOPTION OF

, Adoptee(s). INDIAN CHILD WELFARE ACT AFFIDAVIT I, {full legal name}_______________________, being sworn, certify that the following statements are true: 1. Upon information and belief the child proceeding: [ / one only] {name} subject to this

is not an Indian child. The Indian Child Welfare Act does not apply to this proceeding. is an Indian child within the meaning of the Indian Child Welfare Act of 1978 (25 U.S.C. §1901 et seq.). I certify that a copy of this document was [ / one only] ( ) mailed ( mailed ( ) hand delivered to the person(s) listed below on {date} Other party or his/her attorney: Name: Address: City, State, Zip: Fax Number: I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Party
Printed Name: Address: City, State, Zip: Telephone Number: Fax Number:

) faxed and .

Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit (03/04)

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: [ N fill in all blanks] I, {full legal name and trade name of nonlawyer} , a nonlawyer, located at {street} , {city} , {state} , {phone} , helped {name} , who is the [ / one only] petitioner or respondent, fill out this form.

Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit (03/04)