Notice Of Social Security Number Template With Instructions Page 3
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3I understand that I am swearing or affirming under oath to the truthfulness of the claims made in
this notice and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated:
Signature
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
STATE OF FLORIDA
COUNTY OF ________
by
.
Sworn to or affirmed and signed before me on
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: [ N fill in all blanks]
I, {full legal name and trade name of nonlawyer}
,
a nonlawyer, located at {street}
, {city}
,
, {phone}
, helped {name}
,
{state}
who is the [ / one only]
petitioner or
respondent, fill out this form.
Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number (9/00)
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