IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of DOB: DOB: DOB: DOB:
Minors Under the Age of Eighteen (18) Years
) ) ) ) ) ) ) ) )
CASE NO.
REQUEST FOR COURT SPONSORED CINA MEDIATION or FAMILY GROUP CONFERENCING (FGC) Mediation FGC I am requesting a referral for: OCS Worker AAG GAL Mother (or attorney) Father (or attorney) I am: Tribal Representative Indian Custodian (or attorney) Other legal party I have consulted with all other legal parties and we all agree to make this referral (not required). Other legal parties are listed below. In addition, I may list other persons who should participate. NOTE: If you need to add more names, please attach an additional sheet. Name Relationship Phone(s) and Email address
I think mediation/FGC should focus on the following areas or issues of concern:
Date
I certify that on a copy of this request was sent to: Mother Father OCS Indian Custodian AAG GAL PD Tribe CASA Other Dispute Resolution Coordinator, Karen Largent By:
Signature Type or Print Name Mailing Address City State ZIP
Contact Telephone Number(s)
MED-200 (2/07)(cs) REQUEST FOR COURT SPONSORED CINA MEDIATION/FGC