Parenting Coordinator Report Of An Emergency - Florida Circuit Court Page 4
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4Date :________________
Signature of Parenting Coordinator:__________________
Printed Name: ____________________________________
Address: _________________________________________
City, State, Zip: ____________________________________
Telephone Number: _______________________________
E-mail: __________________________________________
Professional License # (if applicable) ___________________
Professional Certification # (if applicable) ______________
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
deputy clerk.]
_______ Personally known
_______ Produced identification
Type of identification produced ___________________________________________________
Copies to:
_____Presiding Judge
_____Petitioner
_____ Attorney for Petitioner
_____ Respondent
_____ Attorney for Respondent
_____ Other: ____________________________________________________
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was completed with the assistance of:
{name of individual} _____________________________________________________________,
{name of business} _______________________________________________________________,
{address} ______________________________________________________________________,
{city} ____________________,{state} ______________,{telephone number} __________________.
Florida Family Law Rules of Procedure Form 12.984(c), Parenting Coordinator Report of an Emergency (07/14)
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