Waiver of Mandatory Self Help Review - Florida Name Change
IN THE CIRCUIT COURT OF THE ELEVENTH
JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN RE:
CASE NO.:
_____________________________,
Petitioner,
and
_____________________________,
Respondent.
_______________________________/
AFFIDAVIT REQUESTING WAIVER
OF MANDATORY REVIEW BY
THE FAMILY COURT SELF HELP
PROGRAM
I, _________________________________, swear or affirm to the following:
1. That I am filing an action in the Family Division pro se.
2. That I am requesting a waiver of the mandatory review by The Family Court Self Help
Program to proceed with my action for good cause, which is specified as follows:
________________________________________________________________________
__________________________________________________________________________
______________________________________________________________________
________________________________________________________________________
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in the
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated: ________________
Signature of Party: _______________________
Printed Name:
________________________
Street Address:
________________________
City, State, Zip:
________________________
Telephone No.:
________________________
Fax Number:
________________________
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: ___________________________________________
ORDER WAIVING MANDATORY REVIEW BY THE FAMILY COURT SELF HELP PROGRAM
THIS MATTER came before the Court on _____________________________, upon the
litigant¡¯s request to waive mandatory review by the Family Court Self Help Program and it is hereby
GRANTED.
DONE AND ORDERED in Chambers, at Miami-Dade County, Florida this ___________
Day of ________________________________, 20____.
___________________________________
CIRCUIT COURT JUDGE
................
................
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