Eleventh Judicial Circuit Court of Florida



IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUITIN AND FOR MIAMI-DADE COUNTY,FLORIDAFAMILY DIVISIONIN RE: THE MARRIAGE OF:_____________________________,Petitioner,CASE NO.: FCand_____________________________,Respondent._______________________________/SPECIAL AFFIDAVIT FOR UNCONTESTED DISSOLUTION OF MARRIAGE WITHOUT A HEARING(No Children)We, the undersigned, under oath and under penalty of perjury, swear or affirm as follows: Petitioner’s Name ____________________________________________________.I am now married to (Respondent’s Name) _________________________________. We were married on (date) _____________________________________________,In the City/State/Country of ____________________________________________ . We have carefully re-read the Petition for Dissolution of Marriage. Everything stated in it is ( ) true and correct and accurate to the best of our knowledge and belief or ( ) We make the following corrections:__________________________________________________________________________________________________________________________________________________________________One of us at any time thirty days prior to the filing of the Petition for Dissolution of Marriage, was a member of the Armed Forces of the United States, National Guard, or reserve member on active duty, or an active duty commissioned officer of the Public Health Service or the National Oceanic and Atmospheric Administration? ( ) Yes ( ) No 4. Have either you or your spouse resided in the State of Florida continuously as a permanent resident for more than six (6) months before the date the Petition was filed? ( ) Yes ( ) No Which spouse? (write "Husband", "Wife", or "Both") 5. "Irretrievably broken" means that the marriage cannot be salvaged in any way, not even with the help of marriage counseling. Is your marriage irretrievably broken? ( ) Yes ( ) No 6. Are there children born of this marriage who are still minors (under age 18 or still in high school with an anticipated date of graduation prior to age 19)? ( ) Yes ( ) No 7. Is the Wife pregnant at this moment? ( ) Yes ( ) No 8. Have both you and your spouse fully disclosed all assets, liabilities, and incomes to each other? ( ) Yes ( ) No 9. Have you and your spouse both signed a written notarized agreement settling all of the issues in this case? ( ) Yes ( ) No (if NO, please skip to question 15) 10. Do you recognize both your signature and the signature of your spouse on that agreement? ( ) Yes ( ) No 11. Do you believe this agreement is fair? ( ) Yes ( ) No 12. Did both you and your spouse sign this written agreement freely and voluntarily? ( ) Yes ( ) No 13. Were either you or your spouse harassed, coerced or threatened by anyone into signing this agreement? ( ) Yes ( ) No 14. Do you want the Court to adopt this agreement as part of the Final Judgment of Dissolution of Marriage? ( ) Yes ( ) No15. If there is no agreement, do you wish the Court to enter a Final Judgment of Dissolution of Marriage granting the relief requested in the Petition for Dissolution of Marriage? ( ) Yes ( ) No 16. Is the Wife asking the Court to restore her maiden name? ( ) Yes ( ) No (If NO, please skip to question 22)17. The Wife’s wants her maiden name restored to:_____________________________18. The Wife must choose one of the following:a.________I have never been arrested for or charged with, pled guilty or nolo contendere to, or been found to have committed a criminal offense, regardless of adjudication.orb._______ I have a criminal history. In the past I have been arrested for or charged with, pled guilty or nolo contendere to, or been found to have committed a criminal offense, regardless of adjudication. The details of my criminal history are:DateCity/StateEvent (arrest, charge, plea, or adjudication) 19. The Wife must choose one of the following:a. ________I have never been adjudicated bankrupt.orb. ________I was adjudicated bankrupt on {date} , in {city} , {county} , {state} .20. The Wife must choose one of the following:a. ________I have never had a money judgment entered against me by a creditor.orb. ________ The following creditor(s)’ money judgment(s) have been entered against me: ____________________________________________________________________________________________________________________________________ ________I have no ulterior or illegal purpose for filing this petition, and granting it will not in any manner invade the property rights of others, whether partnership, patent, good will, privacy, trademark, or otherwise. 22. Is there anything you believe the Court should know that has not been covered above? If so, briefly state: ( ) Everything is true and correct or ( ) The Court should know the following:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________NOTE: You must show proof that either the Husband or Wife has been a permanent or continuous resident of the State of Florida. Residency cannot be less than six (6) months prior to the date the Petition was filed with the Clerk. You may do this in one of two ways:A. By submitting an enlarged, readable photocopy of a valid Florida driver's license or voter's registration. The date of issue must prove your residency. If it does not, you have failed to prove residency and your case will be held up until proper proof is received; or B. By submitting an Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i). The witness must be someone other than a party to this action and an adult who is a Florida resident. By signing this Special Affidavit, we understand that a final hearing will NOT be set in this case. The Judge assigned to this case may enter a Final Judgment closing the case without our presence at any future hearings.Dated: ________________Petitioner’s Signature: ____________________________STATE OF FLORIDA)COUNTY OF MIAMI-DADE)Sworn to or affirmed and signed before me on ________________ by __________________________.___________________________________NOTARY PUBLIC or DEPUTY CLERK□ Personally known□ Produced identification: ___________________________________________Dated: ________________Respondent’s Signature: ____________________________STATE OF FLORIDA)COUNTY OF MIAMI-DADE)Sworn to or affirmed and signed before me on ________________ by __________________________.___________________________________NOTARY PUBLIC or DEPUTY CLERK□ Personally known□ Produced identification: ___________________________________________ ................
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