Filing # 138182426 E-Filed 11/09/2021 12:21:10 PM
`
`IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT,
`IN AND FOR BROWARD COUNTY, FLORIDA
`
`Case No.: FMCE09006938
`Division: 38/91
`ZACHARY KANEtttttt
`- Petitioner/Father,
`
`and
`
`
`KARINA NORIEGA DE VELIZ
`Respondent/Mother.
`
`UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENTACT
`(UCCJEA) AFFIDAVIT
`
`|, KARINA NORIEGADE VELIZ, being sworn,certify that the following statementsare true:
`
`1. The numberof minorchild(ren) subject to this proceeding is 1. The name, place of birth, birth
`date, and sex of each child; the present address, periods of residence, and places where each
`child has lived within the pastfive (5) years; and the name, present address, and relationship to
`the child of each person with whom the child has lived during that time are:
`
`THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD#
`Child’s Full Legal Name: KIARA LEIGH KANE
`
`Place of Birth: Florida, USA Date of Birth: 07/12/2008. Sex: Female
`
`1
`
`:
`
`
`
`
`
`11/01/2013
`/present*
`
`aeachtloetaye |
`
`Chiid’s Residence for the past 5 years:
`
`
`
`
`Dates
`Address {including city and
`Name and present address of
`Relationship
`
`{From/To}
`to child
`state) where child lived
`person child lived with
`
`
`
`
`KARINA NORIEGADE VELIZ
`
`
`1321 SW 10TH DEERFIELD
`
`BEACH, FL 33441
`WAGNER PESSINI
`
`
`
`1321 SW 10TH DEERFIELD
`
`BEACH, FL 33441
`LUANA VELIZ
`1321 SW 10TH DEERFIELD
`BEACH, FL 33441
`JADE VELIZ
`
`1321 SW 10TH DEERFIELD
`\ BEACH, FL 33441
`
`
` Mother
`
`Stepfather
`sisters
`
`senned
`
`Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement
`Act (UCCJEA) Affidavit (02/18)
`
`FILED: PALM BEACH COUNTY, FL, JOSEPH ABRUZZO, CLERK. 5/24/2022 12:24:02 PM
`
`

`

`
`
`
`
`95/01/2021
`TO
`06/27/2021
`
`12143 Rosedale Terrace,
`Boynton Beachfl
`
`ZACHARY KANE
`WEST DETENTION CENTER
`38811 JAMES WHEELER WAY,
`BELLE GLADE, FL 33430
`
`
`FATHER
`
`
`
`05/0os/o1a019 ¥0
`
`HOTELS
`
`ZACHARY KANE
`
`WEST DETENTION CENTER
`
`38811 JAMES WHEELER WAY,
`BELLE GLADE, FL 33430
`
`05/01/2019 TO
`05/01/2018
`
`2855 N Clearbrook circle
`Delray Beach 33445
`
`ZACHARY KANE
`
`WEST DETENTION CENTER
`38811 JAMES WHEELER WAY,
`
`BELLE GLADE, FL 33430
`
`FATHER
`
`FATHER
`
`FATHER
`
`UNKONWN
`
`05/01/2018 TO
`
`3066 GRANDIFLORA DRIVE
`GREENARES,FL 33467
`
`ZACHARY KANE
`
`WEST DETENTION CENTER
`38811 JAMES WHEELER WAY,
`BELLE GLADE, FL33430
`
`LesseeeEeeOO
`* if you are the petitioner in an injunction for protection against domestic violence case and you have
`filed a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form
`12.980(h), you should write confidential in any space on this form that would require you to enter the
`address where you are currentlyliving.
`
`2. Participation in custody or time-sharing proceeding(s):
`[Choose only one]
`i HAVE NOTparticipated as a party, witness, or in any capacity in any otherlitigation or
`custody proceeding in this or any other state, jurisdiction, or country, concerning parental
`responsibility for, custody of, or time-sharing or visitation with a child subject to this
`proceeding.
`
`| HAVE participated as a party, witness, or in any capacity in any other litigation or
`custody proceeding in this or another state, jurisdiction, or country, concerning parental
`responsibility for, custody of, or time-sharing or visitation with a child subject to this proceeding.
`Explain:
`a. Name of each child:
`b. Type of proceeding:
`
`c. Court and state:
`
`
`
`Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody jurisdiction and Enforcement
`Act (UCCJEA) Affidavit (02/18)
`
`FILED: PALM BEACH COUNTY, FL, JOSEPH ABRUZZO, CLERK. 5/24/2022 12:24:02 PM
`
`

`

`d. Date of court order or judgment (if any):
`
`3.
`
`Information about custody or time-sharing proceeding(s):
`[Chogse only one]
`
`time-sharing, or
`| HAVE NO INFORMATIONofany parental responsibility, custody,
`Vv
`visitation proceeding pendingin a court of this or any other state, jurisdiction, or country
`concerning a child subjectto this proceeding.
`
`| HAVE THE FOLLOWING INFORMATION concerning a parental responsibility, custody,
`time-sharing, or visitation proceeding pending in a courtof this or another state concerning a
`child subject to this proceeding, other than set out in item 2. Explain:
`
`a. Name of each child involvedin said litigation:
`Type of proceeding:
`
`Court and state:
`Date of court order or judgment{if any):
`Case Number:
`
` eaoe
`
`4. Persons not a party to this proceeding:
`[Chooseonly one]
`| DO NOT KNOW OF ANY PERSON in this or any other state, jurisdiction, or country, who
`is not a party to this proceeding and who has physical custody or claims to have parental
`responsibility for, custody of, or time-sharing or visitation with respect to any child subject to
`this proceeding.
`
`5. Knowledgeof prior child support proceedings:
`[Choose only one]
`The child(ren) described in this affidavit are NOT subject to existing child support
`order(s) in this or any other state, jurisdiction, or country..
`JS The child(ren) described in this affidavit are subject to the following existing child
`support order(s):
`Name of each child: KIARA LEIGH KANE
`Type of proceeding: CHILD SUPPORT
`Court and address: 17CIRCUIT COURT
`Date of court order/judgment(if any): 08/29/2016
`Amountof child support ordered to be paid and by whom: $188 TO ZACHARY KANE
`
`paoow
`
`6.
`
`l|acknowledge that I have a continuing duty to advise this Court of any parental responsibility,
`custody, time-sharing orvisitation , child support, or guardianship proceeding {including |
`dissolution of marriage, separate maintenance, child neglect, or dependency) concerning the
`child(ren) in this state or any other state about which information is obtained during this
`proceeding.
`
`7. Acompleted Notice of Confidential Information within Court Filing, Florida Rules of Judicial
`
`Fiorida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement
`Act (UCCIEA) Affidavit (02/18)
`
`FILED: PALM BEACH COUNTY, FL, JOSEPH ABRUZZO, CLERK. 5/24/2022 12:24:02 PM
`
`

`

`Administration Appendix to Rule 2.420 Form, is Hed with this Affidavit.
`
`+} faxed and mailed
`=) mailed({
`=} e-served(
`| certify that a copy of this document was(
`{ A hand delivered to the person(s) listed below on {date} BY PROCESS SERVER
`
`Other party or his/her attorney:
`Name: ZACHARY KANE
`WEST DETENTION CENTER
`38811 JAMES WHEELER WAY,
`BELLE GLADE, FL 33430
`| understand that | am swearing or affirming under oath to the truthfulness of the clalms madein this
`affidavit and that the punishment for knowingly making a false statementincludes finesand/or
`Imprisonment.
`.
`
`Dated:
`11/09/2021
`;
`avina
`de UE22.
`
`Signature of Respondent/Mother
`Printed Name: KARINA NORIEGA DE VELIZ
`Address: 321 SW 10'™ OEERFIELO BEACH, FL 33441
`Telephone Number: (954) 254-4032
`
`STATE OF FLORIDA
`COUNTY OF BROWARD
`
`Sworn to.or affirmed and signed before me on 30972021 by KARINANORIEGADEVELIZ,
`
`
`
`byRe‘ Convnlssion#GG959309
`i
`», LNDACASMELAORREGO
`‘
`# Expires Jura 14,2024
`
`Banded ThaeyFal hewranceMSIg NEea
`
`NOTARY PUBLIC
`
`[Print, type, or stamp commissioned name of notary orclerk.}
`Se
`vw Produced identification
`a
`Type of identification produced—FLORIDA ORIVER'S LICENSE
`
`Florida Supreme Court Approved Family Law Form 12.902{d)}, Uniform Child Custody Jurisdiction and Enforcement
`Act (UCCIEA) Affidavit (02/18)
`
`FILED: PALM BEACH COUNTY,FL, JOSEPH ABRUZZO, CLERK. 5/24/2022 12:24:02 PM
`
`