IN THE CIRCUIT COURT OF THE                                                       JUDICIAL CIRCUIT,
IN AND FOR                                                       COUNTY, FLORIDA

Case No.: 	
Division: 	
                                                                      ,
Petitioner,

and

                                                                       ,
Respondent.

DESIGNATION OF CURRENT MAILING AND E-MAIL ADDRESS

I, {full legal name}, _________________________________________, being sworn, certify that:					
				                MAILING ADDRESS:
My current mailing address is: 
{Street or Post Office Box} _________________________________________________________, 
{City}, ___________________________________, {State}, _____________, {Zip}_____________.
{Telephone No.} 	_____________ {Fax No.} ______________________.
					
E-MAIL ADDRESS**:
The following is/are my e-mail address(es) for the purposes of serving and receiving documents: 
Primary e-mail address: _________________________________________________________________________________
Secondary  e-mail address(s):  (May designate up to two secondary e-mail addresses): _________________________________________________________________________________

I understand that I must keep the clerk’s office and the opposing party or parties notified of my current mailing and e-mail address(es) and that all future papers in this lawsuit will be served at the e-mail address(es) on record at the clerk’s office. 

I certify that a copy of this document was _____ e-mailed _____ 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: _________________________
Designated E-mail Address(es): ___________
__________________________________

						_____________________________________________	
	                                            		Signature of Party

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	
       _	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] This form was prepared for the: {choose only one} _____ Petitioner _____ Respondent
This form was completed with the assistance of:
{name of individual} ______________________________________________________________,
{name of business} _______________________________________________________________,
{street} 					______________________________________________, 
{city} 	                                         ,{state} 	__, {zip code}______,{telephone number}____