Response By Parenting Coordinator - Florida Circuit Court Page 4
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4I hereby affirm the truth of the statements in this acceptance and understand that if I make any false
representations in this acceptance, I am subject to sanctions by the Court.
_____________________
_____________________________________________
Date
Signature of Parenting Coordinator
Printed Name:_________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: ____________________________
E-mail: _______________________________________
Professional License # (if applicable) _______________
Professional Certification # (if applicable) ____________
Copies to:
_____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(b), Response by Parenting Coordinator (07/14)
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