Petition For Dissolution Of Marriage With Dependent Or Minor Child(Ren) Page 10
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11__________________________________________________________________________________
6. Petitioner requests that life insurance to secure child support be provided by:
a. ___Father.
b. ___Mother.
c. ___Both.
SECTION V. OTHER
1. [If Petitioner is also the Wife, please indicate by either ( ) yes ( ) or no whether Petitioner/Wife
wants to be known by her former name, which was {full legal name}
__________________________________________________________________________________
2. Other relief {specify}:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
SECTION VI. PETITIONER’S REQUEST (This section summarizes what you are asking the Court to include
in the final judgment of dissolution of marriage.)
Petitioner requests that the Court enter an order dissolving the marriage and:
[Choose all that apply]
1. ___distributing marital assets and liabilities as requested in Section I of this petition;
2. ___awarding spousal support (alimony) as requested in Section II of this petition;
3. ___ adopt or establish a Parenting Plan containing provisions for parental responsibility and time-
sharing for the dependent or minor child(ren) common to both parties, as requested in Section III of
this petition;
4. ___establishing child support for the dependent or minor child(ren) common to both parties, as
requested in Section IV of this petition;
5. ___restoring Wife’s former name as requested in Section V of this petition-
6. ___awarding other relief as requested in Section V of this petition; and any other terms the Court
deems necessary.
I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this petition and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.
Dated: ______________________
_____________________________________________
Signature of PETITIONER
Printed Name: _________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of Marriage with
Dependent or Minor Child(ren) (10/11)
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