Answer, Waiver, And Request For Copy Of Final Judgment Of Dissolution Of Marriage Page 5
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5I certify that a copy of this document was [Choose only one] ( ) mailed ( ) faxed and mailed
( ) hand delivered to the person(s) listed below on {date} _____________________________________
Other party or his/her attorney:
Name: ________________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: __________________________________
I 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.
Dated: ______________________
_______________________________________
Signature of RESPONDENT
Printed Name: ___________________________
Address: _______________________________
City, State, Zip: __________________________
Telephone Number: ______________________
Fax Number: ___________________________
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 ________________________________
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in
all blanks]
I, {full legal name and trade name of nonlawyer} _____________________________________________,
a nonlawyer, whose address is {street} __________________________, {city} _____________________,
{state} ______________,{phone} ______, helped {name} _______________________________, who is
the respondent, fill out this form.
Answer, Waiver, and Request for Copy of Final Judgment of Dissolution of Marriage, Florida Supreme Court
Approved Form 12.903(a)(12/10)
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