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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.980(h), PETITIONER'S REQUEST FOR CONFIDENTIAL FILING OF ADDRESS When should this form be used? If you are the petitioner seeking an injunction for protection against domestic violence or sexual violence and you fear that disclosing your address to the respondent would put you in danger, you should complete this form and file it with the clerk of the circuit court. You cannot use this form in a petition for injunction for protection against repeat or dating violence action. This form should be typed or printed in black ink. After completing this form, you should file the original with the clerk of the circuit court in the county where your petition was filed and keep a copy for your records.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(h), Petitioner's Request for Confidential Filing of Address (07/04)

IN THE CIRCUIT COURT OF THE IN AND FOR

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

Petitioner, and , Respondent. PETITIONER'S REQUEST FOR CONFIDENTIAL FILING OF ADDRESS I, {full legal name} , Petitioner in the above action, request that the Court maintain and hold as confidential, the following address: Address City Telephone (area code and number) State Zip

This request is being made for the purpose of keeping the location of my residence unknown to Respondent for safety reasons pursuant to section 741.30, Florida Statutes, or section 784.046, Florida Statutes. Dated: Signature of Petitioner CLERK'S CERTIFICATE AS TO PETITIONER'S REQUEST FOR CONFIDENTIAL FILING OF ADDRESS I, , as Clerk of the Circuit Court, do hereby certify that I received and filed the above and will keep the above address confidential, subsequent to further order of the Court relative to such confidentiality. CLERK OF THE CIRCUIT COURT (SEAL) By: Deputy Clerk
Florida Supreme Court Approved Family Law Form 12.980(h), Petitioner's Request for Confidential Filing of Address (07/04)