Motion To Deviate From Child Support Guidelines Page 4
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4I understand that I am swearing or affirming under oath to the truthfulness of the claims made
in this motion and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.
Date: __________________
Nov. 21, 2012
_________________________________________________
Signature of Party or his/her attorney
Printed Name: ____________________________________
Martha C. Sample
Address: ________________________________________
200 Eldon Lane
City, State, Zip: ___________________________________
Pensacola, FL 32502
Telephone Number: ________________________________
850-123-4444
Fax Number: _____________________________________
850-123-7777
Email Address: ____________________________________
STATE OF FLORIDA
Escambia
COUNTY OF _________________________________
Sworn to or affirmed and signed before me on __________________ by ______________________
Nov. 21, 2012
Martha C. Sample
___________________________________________
NOTARY PUBLIC or DEPUTY CLERK
Clyde Groten
___________________________________________
Print, type, or stamp commissioned name of notary
or clerk.]
____ Personally known
x
____ Produced identification
Type of identification produced _____________________________
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS
[fill in
blanks] This form was prepared for the:
BELOW:
all
{choose only one}
(
) Petitioner (
) Respondent
{name of individual} _________________________________________________________________,
{name of business} _________________________________________________________________,
Attorney for Martha Sample
{address} _________________________________________________________________________,
{city} _______________________ {state} _______ {telephone number} _______________________.
Case number: FA-2012-489
Submitter name: Martha C. Sample
Date: 8/2/2013
Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support
Page 4
Guidelines (10/11)
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