SETTLEMENT AGREEMENT ON PETITION TO DETERMINE

14th Judicial Circuit Approved Form, Settlement Agreement on Petition to Determine Paternity and for Related

Relief (06/16)

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IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT

IN AND FOR ______________ COUNTY, FLORIDA

_______________________________,

Petitioner,

Case No. _____________________

and Division: _____________________

_______________________________,

Respondent.

SETTLEMENT AGREEMENT ON PETITION TO DETERMINE PATERNITY

AND FOR RELATED RELIEF

We, ________________________________________________, Father, and

________________________________________________, Mother, being sworn, certify that the

following statements are true:

1. We have made this agreement to settle the issues involving our minor or dependent

child(ren).

2. We both have filed Family Law Financial Affidavit, Florida Rules of Procedure Form 12.902

(b) or (c). Because we have voluntarily made full and fair disclosure to each other of all our

assets and debts, we waive any further disclosure under ruled 12.285 Florida Family Law

Rules of Procedure.

3. Each of us agrees to execute and exchange any papers that might be needed to complete this

agreement, including but not limited to, insurance cards, birth certificates and social security

information regarding the minor or dependent child(ren).

SECTION I. PATERNITY

1. The Father, __________________________, and the Mother, ________________________,

are the biological, or legal parents of the minor or dependent child(ren) listed below:

The parties’ dependent or minor child(ren) is (are):

Name: Birth Date: Emancipation Date:

____________________________ __________________ ________________

14th Judicial Circuit Approved Form, Settlement Agreement on Petition to Determine Paternity and for Related

Relief (06/16)

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SECTION II: PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND

TIME-SHARING

The Parties shall have time-sharing and parental responsibility in accordance with the parenting

plan attached as Exhibit __________.

SECTION III. CHILD SUPPORT (check one)

1. _______ The ( ) Father ( ) Mother is currently ordered to pay child support in the amount

of $__________ per _______ as ordered in the case of ______________________ (Case

Name) ______________, (Case Number), entered on _________________(date signed by

judge), in the __________Circuit ____________ County, __________________, (State).

Child Support shall continue to be paid as previously established.

OR

_______ The ( ) Father ( ) Mother shall pay child support on a monthly basis in the

amount of:

The child support amount for three children per month is $_____________.

The child support amount for two children per month is $_____________.

The child support amount for one child per month is $_____________.

The first payment shall be due on ________________, and continue each month. All payments shall be

payable (check one only):

________ Directly to the ( ) Father ( ) Mother

________ To the State of Florida Disbursement Unit, Post Office Box 8500, Tallahassee,

Florida 32314-8500

________ Payments shall be made through Income Withholding Order

Said child support shall continue until the youngest child marries, becomes self-supporting, or reaches the

age of majority, whichever occurs first, unless otherwise directed by the Court. An exception to the

termination of the child support obligation shall occur for any child who upon reaching his or her

eighteenth birthday has not completed high school, but who is making satisfactory progress toward high

school completion prior to his or her nineteenth birthday. In such a situation, child support shall continue

until the child completes high school prior to his or her nineteenth birthday.

If the child support amount above deviates from the guidelines by 5% or more, explain the reason(s) here:

____________________________________________________________________________________.

14th Judicial Circuit Approved Form, Settlement Agreement on Petition to Determine Paternity and for Related

Relief (06/16)

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2. Child Support Arrearage. There is a child support arrearage of $

___________________ for retroactive child support and/or $_______________for previously ordered

unpaid child support for a total of $________________ in child support arrearage. This amount shall be

repaid at the rate of $ __________ every ( ) week ( ) bi-weekly ( ) semi-monthly ( ) month, beginning

__________, until paid in full including statutory interest.

3. Health Insurance. (Choose one only)

a. _______ ( ) Father ( ) Mother will maintain health insurance for the parties’ minor

child(ren). The party providing coverage will provide insurance cards to the other party

showing coverage within 30 days of the date of this order.

OR

______ The child(ren) are covered by Medicaid or other state funded insurance. The ( )

Father

( ) Mother shall maintain the insurance as long as the child(ren) is (are) eligible.

OR

______ Health insurance is either not reasonable in cost or accessible to the child(ren) at

this time.

b. Any reasonable and necessary uninsured/unreimbursed medical costs for the minor

child(ren) shall be assessed as follows:

_______ Shared equally by both parents or

_______ Prorated according to the child support guideline percentages. Or

_______ other: (explain)___________________________________________________

_______________________________________________________________________.

As to these uninsured/unreimbursed medical expenses, the party who incurs the expense shall

submit a request for reimbursement to the other party within 30 days, and the other party,

within 30 days of receipt, shall submit the applicable reimbursement for that expense,

according to the schedule of reimbursement set out in this paragraph.

4. Dental Insurance. (choose one only)

a. _______ ( ) Father ( ) Mother will maintain health insurance for the parties’ minor

child(ren). The party providing coverage will provide insurance cards to the other party

showing coverage within 30 days of the date of this order.

OR

______ The child(ren) are covered by Medicaid or other state funded insurance. The ( )

Father

( ) Mother shall maintain the insurance as long as the child(ren) is (are) eligible.

OR

______ Health insurance is either not reasonable in cost or accessible to the child(ren) at

this time.

14th Judicial Circuit Approved Form, Settlement Agreement on Petition to Determine Paternity and for Related

Relief (06/16)

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b. Any reasonable and necessary uninsured/unreimbursed medical costs for the minor

child(ren) shall be assessed as follows:

_______ Shared equally by both parents or

_______ Prorated according to the child support guideline percentages. Or

_______ other: (explain)___________________________________________________

_______________________________________________________________________.

As to these uninsured/unreimbursed medical expenses, the party who incurs the expense shall

submit a request for reimbursement to the other party within 30 days, and the other party,

within 30 days of receipt, shall submit the applicable reimbursement for that expense,

according to the schedule of reimbursement set out in this paragraph.

5. Life Insurance. ( ) Father ( ) Mother shall be required to maintain life insurance coverage

for the benefit of the parties’ minor child(ren) in the amount of

$_________________________ until the youngest child turns 18, becomes emancipated,

marries, joins the armed services, dies or otherwise becomes self-supporting.

6. IRS Income Tax Deduction(s). The assignment of any tax deductions for the child(ren)

shall be as follows: (explain) __________________________________________________

__________________________________________________________________________.

The other parent will convey any applicable IRS form regarding the income tax deduction.

7. Other provisions relating to child support (e.g, uninsured medical/dental expenses, health or

dental insurance, life insurance to secure child support, orthodontic payments, college fund,

etc.):

___________________________________________________________________________

__________________________________________________________________________.

SECTION IV. OTHER

______________________________________________________________________________

______________________________________________________________________________.

SECTION V. We have not agreed on the following issues:

______________________________________________________________________________

_____________________________________________________________________________.

14th Judicial Circuit Approved Form, Settlement Agreement on Petition to Determine Paternity and for Related

Relief (06/16)

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I certify that I have been open and honest in entering into this settlement agreement. I am satisfied

with this agreement and intend to be bound by it.

Dated: ________________________ __________________________________________

Signature of Father

Printed Name: _______________________________

Address: ___________________________________

City, State, Zip: ______________________________

Phone: _____________________________________

Email address: _______________________________

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 clerk.)

_____ Personally Known to me

_____ Produced Identification

Type of Identification Produced:_____________________

IF A NON-LAWYER 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 non-lawyer) ____________________________________________,

A non-lawyer, whose address is ___________________________________________________________

helped __________________________________ who is the (choose only one) ( ) Petitioner or

( ) Respondent, fill out this form.

14th Judicial Circuit Approved Form, Settlement Agreement on Petition to Determine Paternity and for Related

Relief (06/16)

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I certify that I have been open and honest in entering into this settlement agreement. I am satisfied

with this agreement and intend to be bound by it.

Dated: ________________________ __________________________________________

Signature of Mother

Printed Name: _______________________________

Address: ___________________________________

City, State, Zip: ______________________________

Phone: _____________________________________

Email address: _______________________________

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 clerk.)

_____ Personally Known to me

_____ Produced Identification

Type of Identification Produced:_____________________

IF A NON-LAWYER 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 non-lawyer) ____________________________________________,

A non-lawyer, whose address is ___________________________________________________________

helped __________________________________ who is the (choose only one) ( ) Petitioner or

( ) Respondent, fill out this form.