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IN THE CIRCUIT COURT OF THE IN AND FOR

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

, Petitioner, and , Respondent.

TEMPORARY INJUNCTION TO PREVENT REMOVAL OF MINOR CHILD(REN) AND/OR DENIAL OF PASSPORT SERVICES (EX PARTE) Upon verified motion of ( ) Petitioner ( ) Respondent, the Court has jurisdiction of the parties and the subject matter and the Court being fully advised, it is ORDERED and ADJUDGED that: NOTICE OF HEARING This Temporary Injunction to Prevent Removal of Child(ren) has been issued without prior notice to Respondent. Pursuant to Rule 1.610, Florida Rules of Civil Procedure, the other party may file a motion to dissolve or modify this temporary injunction and a hearing will be scheduled within 5 days of that motion. [ if applies] _____ If no motion to dissolve is filed, Petitioner and Respondent are instructed that they are scheduled to appear and testify at a hearing regarding this matter on {date}___________, at _______ a.m./p.m., when the Court will consider whether the Court should continue, modify, or dissolve this Temporary Injunction to Prevent Removal of Child(ren) and/or Denial of Passport Services, which would remain in effect until modified or dissolved by the Court, and whether other things should be ordered, including who should pay the filing fees and costs. The hearing will be before The Honorable {name}___________________________________________, at {room name/number, location, address, city}_________________________________________________________, Florida. If Petitioner and/or Respondent do (does) not appear, this temporary injunction may be continued in force, extended, or dismissed, and/or additional orders may be issued, including the imposition of court costs. _____ If you are a person with a disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact {name}__________________________,{address}____________________________________________, {telephone}______________________ , within 2 working days of your receipt of this temporary injunction. If you are hearing or voice impaired, call TDD 1-800-955-8771.

Florida Supreme Court Approved Family Law Form 12.941(b), Temporary Injunction to Prevent Removal of Minor Child(ren) and/or Denial of Passport Services (Ex Parte) (03/09)

FINDINGS 1. It appears from specific facts shown by verified motion that immediate and irreparable injury, loss, or damage will result to the minor child(ren) if a temporary injunction is not issued without notice to the other party. 2. ( ) Petitioner's ( ) Respondent's attorney has certified in writing any efforts made to give notice. 3. The reasons why notice should not be given are: _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ TEMPORARY INJUNCTION [ all that apply] 1. ____The following child(ren) shall not be removed from the jurisdiction of this Court during the pendency of this proceeding, or until further order of this Court: Name Birth date ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 2. ____ ( ) Petitioner ( ) Respondent shall not apply for any passports or passport services on behalf of the child(ren). 3. ____ ( ) Petitioner ( ) Respondent shall immediately deliver any existing passports for the child(ren) to {name} _____________________________________________________________. 4. The Court may enforce compliance with the terms of this injunction through civil and/or indirect criminal contempt proceedings, which may include arrest, incarceration, and/or the imposition of a fine. 5. Violation of this injunction may constitute criminal contempt of court. 6. Bond. a. ___ Bond is waived because this injunction is issued solely to prevent physical injury or abuse of a natural person. b. ___ This order is conditioned upon ( ) Petitioner ( ) Respondent posting bond in the sum of $ _______ with the clerk of this Court. 7. Expiration. This injunction shall remain in effect until the minor child(ren) reach(es) the age of 18, until the hearing scheduled herein, if any, or {date} ___________, whichever occurs first, unless modified by further order of this Court. ORDERED on {date} _________________ , at{time} _________________. __________________________________________ CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.941(b), Temporary Injunction to Prevent Removal of Minor Child(ren) and/or Denial of Passport Services (Ex Parte) (03/09)

A copy of the {name of document(s)} ______________________________________________ was [only one] ( ) 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) Respondent (or his or her attorney) U.S. Department of State Office of Children's Issues 2201 "C" Street NW CA/OCS/CI Washington, D.C. 20520 Fax (202) 736-9133 [email protected]

Florida Supreme Court Approved Family Law Form 12.941(b), Temporary Injunction to Prevent Removal of Minor Child(ren) and/or Denial of Passport Services (Ex Parte) (03/09)