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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.995(b), SUPERVISED/SAFETY-FOCUSED PARENTING PLAN (03/09)
When should this form be used?
A Parenting Plan is required in all cases involving minor child(ren). This form or a similar form should be used in cases when you feel your child(ren) cannot be safely alone with the other parent or if you believe shared parental responsibility presents a detriment to the child(ren). In this case, a Parenting Plan must be developed that allows time-sharing with any minor child(ren), while providing protection for the child(ren). If safety or supervised time-sharing is not a concern, Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(a) should be used. This form should be typed or printed in black ink. If an Agreement has been reached, both parties must sign the Parenting Plan and have their signatures witnessed by a notary public or deputy clerk. After completing this form, you should 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. You should then refer to the instructions for your petition, answer, or answer and counterpetition concerning the procedures for setting a hearing or trial (final hearing). If an agreed Parenting Plan is not filed by the parties, the Court shall establish a Plan.

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. For further information, see chapter 61, Florida Statutes, and the instructions for the petition and/or answer that were filed in this case.

Special notes...
At a minimum, the Parenting Plan must describe in adequate detail: How the parties will share and be responsible for the daily tasks associated with the upbringing of the child(ren), The time-sharing schedule arrangements that specify the time that the minor child(ren) will spend with each parent, A designation of who will be responsible for any and all forms of health care, school-related matters, other activities, and The methods and technologies that the parents will use to communicate with the child(ren). The best interests of the child(ren) is the primary consideration in the Parenting Plan. In creating the Parenting Plan, all circumstances between the parties, including the parties' historic relationship, domestic violence, and other factors must be taken into consideration. Determination of the best
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

interests of the child(ren) shall be made by evaluating all of the factors affecting the welfare and interest of the minor child(ren), including, but not limited to: The demonstrated capacity and disposition of each parent to facilitate and encourage a close and continuing parent-child relationship, to honor the time-sharing schedule, and to be reasonable when changes are required; The anticipated division of parental responsibilities after the litigation, including the extent to which parental responsibilities will be delegated to third parties; The demonstrated capacity and disposition of each parent to determine, consider, and act upon the needs of the child(ren) as opposed to the needs or desires of the parent; The length of time the child(ren) has lived in a stable, satisfactory environment and the desirability of maintaining continuity; The geographic viability of the parenting plan, with special attention paid to the needs of schoolage children and the amount of time to be spent traveling to effectuate the parenting plan. This factor does not create a presumption for or against relocation of either parent with a child(ren); The moral fitness of the parents; The mental and physical health of the parents; The home, school, and community record of the child(ren); The reasonable preference of the child(ren), if the court deems the child(ren) to be of sufficient intelligence, understanding, and experience to express a preference; The demonstrated knowledge, capacity, and disposition of each parent to be informed of the circumstances of the minor child(ren), including, but not limited to, the child(ren)'s friends, teachers, medical care providers, daily activities, and favorite things; The demonstrated capacity and disposition of each parent to provide a consistent routine for the child(ren), such as discipline, and daily schedules for homework, meals, and bedtime; The demonstrated capacity of each parent to communicate with and keep the other parent informed of issues and activities regarding the minor child(ren), and the willingness of each parent to adopt a unified front on all major issues when dealing with the child(ren); Evidence of domestic violence, sexual violence, child abuse, child abandonment, or child neglect, regardless of whether a prior or pending action relating to those issues has been brought; Evidence that either parent has knowingly provided false information to the court regarding any prior or pending action regarding domestic violence, sexual violence, child abuse, child abandonment, or child neglect; The particular parenting tasks customarily performed by each parent and the division or parental responsibilities before the institution of litigation and during the pending litigation, including the extent to which parenting responsibilities were undertaken by third parties; The demonstrated capacity and disposition of each parent to participate and be involved in the child(ren)'s school and extracurricular activities; The demonstrated capacity and disposition of each parent to maintain an environment for the child(ren) which is free from substance abuse; The capacity and disposition of each parent to protect the child(ren) from the ongoing litigation as demonstrated by not discussing the litigation with the child(ren), not sharing documents or

Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)



electronic media related to the litigation with the child(ren), and refraining from disparaging comments about the other parent to the child)ren); and The developmental stages and needs of the child(ren) and the demonstrated capacity and disposition of each parent to meet the child(ren)'s developmental needs.

This standard form does not include every possible issue that may be relevant to the facts of your case. The Parenting Plan should be as detailed as possible to address the time-sharing schedule. Additional provisions should be added to address all of the relevant factors. The parties should give special consideration to the age and needs of each child. In developing the Parenting Plan, you may wish to consult or review other materials which are available at your local library, law library or through national and state family organizations. 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, 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 Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT IN AND FOR _________________ COUNTY, FLORIDA Case No: _____________________ Division: _____________________ _______________________________ Petitioner, and _______________________________ Respondent.

SUPERVISED/SAFETY-FOCUSED PARENTING PLAN
This parenting plan is: (Choose only one) [ } A Parenting Plan submitted to the court with the agreement of the parties. { } A proposed Parenting Plan submitted by or on behalf of: (Parent's Name)_________________________________________. [ ] A Parenting Plan established by the court. This parenting plan is: (Choose only one) [ ] A final Parenting Plan established by the court. [ ] A temporary Parenting Plan established by the court. [ ] A modification of a prior final Parenting Plan or prior final order. I. PARENTS Mother Name:__________________________________________________________________ Address:________________________________________________________________ Telephone Number:_______________________________________________________ E-Mail:_________________________________________________________________ Father Name:__________________________________________________________________ Address:________________________________________________________________ Telephone Number: _______________________________________________________ E-Mail: _________________________________________________________________ II. CHILDREN: This parenting plan is for the following child(ren) born to, or adopted by the parties: (add additional lines as needed) Name Date of Birth Sex _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

_______________________________________________________________________ III. JURISDICTION The United States is the country of habitual residence of the child(ren). The State of Florida is the child(ren)'s home state for the purposes of the Uniform Child Custody Jurisdiction and Enforcement Act. This Parenting Plan is a child custody determination for the purposes of the Uniform Child Custody Jurisdiction and Enforcement Act, the International Child Abduction Remedies Act, 42 U.S.C. Section 11601 et seq., the Parental Kidnapping Prevention Act, and the Convention on the Civil Aspects of International Child Abduction enacted at the Hague on October 25, 1980, and for other state and federal laws. Other: _________________________________________________________________. IV. PARENTAL RESPONSIBILITY (Choose only one) [ ] [ ] It is in the best interests of the child(ren) that the [ ] Mother [ ]Father shall have sole authority to make major decisions for the child(ren.) Shared Parental Responsibility with Decision Making Authority It is in the best interests of the child(ren) that the parents confer and attempt to agree on the major decisions involving the child(ren). If the parents are unable to agree, the authority for making major decisions regarding the child(ren) shall be as follows: Education/Academic decisions Non-emergency health care ___________________________ ___________________________ ___________________________ [ ] [ [ [ [ [ ] Mother ] Mother ] Mother ] Mother ] Mother [ [ [ [ [ ] Father ] Father ] Father ] Father ] Father

Other: (Explain) __________________________________________________.

V. TIME SHARING SCHEDULE (Choose only one) [ ] No Time-Sharing: The [ ] Mother [ ] Father shall have no contact with the child(ren) until further order of the court. All parenting decisions shall be made by the other parent. Supervised Time-Sharing: Whenever the child(ren) are with the [ ] Mother [ ] Father, the supervisor shall be present. The [ ] Mother [ ] Father has the right to spend time with the child(ren) even though the other parent will be making most, if not all, of the parenting decisions which are made on the child(ren)'s behalf. The time-sharing

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Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

schedule shall be mutually agreed to between the parents, but not less than the schedule set forth below: (Choose only one) [ ] ____________ hours per week. The place(s), and time(s) shall be set by the [ ] Mother [ ]Father. From ________ __ m. to ____________ __ m, on the following day(s) ______________________________________________. Other: _____________________________________________________________.

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VI. SUPERVISOR AND SUPERVISION (Choose only one) 1. Supervisor. The person supervising the time-sharing shall: (Choose only one) [ ] Be selected by the [ ] Mother [ ] Father. [ ] [ ] Be selected by the [ ] Mother [ ] Father, subject to the other parent's approval. Other: ____________________________________________________________.

2. Restrictions or Level of Supervision: _________________________________________ _____________________________________________________________________ _____________________________________________________________________ . 3. Costs of Supervision [ ] The costs of the supervision shall be paid by the [ ] Mother [ ] Father [ ] Other: ______________________________________________________.

VII. LOCATION: (Choose only one) The [ ] Mother [ ] Father shall spend his/her time-sharing with the child(ren) at the following location(s): [ ] Supervised visitation center (name of facility) _____________________________ ________________________________________________________________. _____________________ (location) or other location designated by the [ ] Mother [ ] Father

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Any location designated by the [ ] Mother [ supervisor.

] Father with the approval of the

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Other: ___________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

VIII. DESIGNATION FOR OTHER LEGAL PURPOSES 1. The child(ren) named in this Supervised/Safety-Focused Parenting Plan are scheduled to reside the majority of the time with the [ ] Mother [ ] Father. This majority designation is SOLELY for purposes of all other state and federal statutes which require such a designation. This designation does not affect either parent's rights and responsibilities under this parenting plan. 2. For purposes of school boundary determination and registration, the [ ] Mother's [ ] Father's address shall be designated. IX. TRANSPORTATION AND EXCHANGE OF CHILD(REN) 1. Transportation The child(ren) shall not be driven in a car unless the driver has a valid driver's license, automobile insurance, seat belts, and child safety seats as required by Florida law. The [ ] Mother [ ] Father or mutually agreed upon person shall be responsible for transporting the child(ren) to the exchange point. The child(ren) shall be picked up and/or returned to the exchange point by (Choose only one); [ ] [ ] [ ] [ ] The [ ] Mother [ ] Father with the supervisor present. The supervisor alone. A monitored exchange location (specify) __________________________________. Other: ____________________________________________________________.

2. Exchange The exchange of the child(ren) shall occur at: (Choose all that apply) [ ] [ ] [ ] IX. The site of the supervised visit. Other: _____________________________________________________. The [ ] Mother [ ] Father may not come to the exchange point. COMMUNICATION 1. Between Parents (Choose only one) [ ] All communications regarding the child(ren) shall be between the parents. The parents shall not use the child(ren) as messengers to convey information, ask questions, or set up schedule changes.

Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

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The parents shall communicate with each other by: (Choose all that apply) in person by telephone by letter by e-mail Other:________________________________________________________________.

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No Communication. Unless otherwise prohibited by court order, all information and communication regarding the child(ren) shall be exchanged via or through ______________________________________________________________________. 2. Between Parent and Child(ren) The [ ] Mother [ ] Father (Choose all that apply) [ ] Shall not telephone, write, or e-mail the child(ren) unless the contact is agreed to in advance by the other parent. May write or e-mail the child(ren) at any time. Each parent shall provide a contact address (and e-mail address if appropriate) to the other parent, unless other prohibited by court order. May call the child(ren) on the telephone ___ times per week. The call shall last no more than ____ minutes and shall take place between _____ __m. and _____ __ m.. Long distance telephone calls made by the child(ren) shall be paid for by the parent receiving the call. Each parent shall provide a telephone number to the other parent, unless otherwise prohibited by court order. Other: ____________________________________________________________.

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3. Costs of Electronic Communication "Electronic communication" includes telephones, electronic mail or e-mail, webcams, videoconferencing equipment and software or other wired or wireless technologies or other means of communication to supplement face-to face contact. The costs of electronic communication shall be addressed as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________. X. ACCESS TO ACTIVITIES AND EVENTS The [ ] Mother [ ] Father [ ] Shall not attend the child(ren)'s activities and events, including but not limited to, school, athletic, and extra-curricular activities and events.

Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

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May attend the child(ren)'s school, athletic, and extra-curricular activities and events. The [ ] Mother [ ] Father must stay ___ feet from the other parent and ___ feet from the child.

[ ] Other ___________________________________________________________________. XI. CHILD(REN)'S SAFETY

The [ ] Mother [ ] Father shall follow the safety rules checked below. (Choose all that apply) [ ] There shall be no firearms in the home, car, or in the child(ren)'s presence during timesharing. No alcoholic beverages shall be consumed from twenty-four (24) hours before the child(ren) arrive until they are returned to the other parent. The child(ren) shall not be disciplined by corporal punishment. The following person(s) present a danger to the child(ren) and shall not be present during time-sharing: ____________________________________________________. Other: _____________________________________________________________. CHANGES OR MODIFICATIONS OF THE PARENTING PLAN

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[ ] XII.

All changes to the Supervised/Safety-Focused Parenting Plan must be pursuant to a court order. XIII. OTHER PROVISIONS ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________________ ________________________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

SIGNATURE OF PARENTS I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this Plan and intend to be bound by it.

Dated:

_____________________________________________ Signature of Mother 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 _________________________________ I certify that I have been open and honest in entering into this settlement agreement. I am satisfied with this agreement and intend to be bound by it.

Dated: ________________________

_____________________________________________ Signature of Father Printed Name: Address: City, State, Zip: Telephone Number: Fax Number:

Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)

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

ORDER OF THE COURT IT IS ORDERED AND ADJUDGED THAT THE PARENTING PLAN SET FORTH ABOVE IS ADOPTED AND ESTABLISHED AS AN ORDER OF THIS COURT. ORDERED ON ___________________________. __________________________________ CIRCUIT JUDGE COPIES TO: Father (or his Attorney) Mother (or her Attorney) Other

Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/09)