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ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NO:

For Court Use Only

__
ATTORNEY FOR: (Name) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: 3341 Power Inn Road MAILING ADDRESS: Same CITY AND ZIP CODE: Sacramento, CA 95826 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT:

PETITION FOR PRIVATE MEDIATION
Local Rules 14.08(H)

CASE NUMBER:

1. Date of last Mediation Report: _______/_______/________ 2. 3. 4. 5. 6. 7. Do you currently have an appointment set for FCS mediation? If so, when: ______/______/______ Have you been to Family Court Services before? If so, when? _______/_______/_______ Have you been to private mediation before? If so, when? _______/_______/_______ Do you have a current Domestic Violence Restraining Order? o Yes (attach copy) Do you have an existing court order for custody/visitation? o Yes (attach copy) o No o No

Issues to be mediated concern custody and visitation of the following named child(ren): ___________ _________________________________________________________________________________

8.

o Request that one of the following private mediators be appointed: ____________________________________ _____________________________________

9.

o Declarant shall advance the cost of private mediation subject to the court reserving the right to order reimbursement from the other party. Any information I have provided above and any attachment to this Petition is furnished in good faith in the hope of settling the controversy. I declare under penalty of perjury under the laws of the State of California that the foregoing information is true and correct. Date: ______/______/______ __________________________________________ Signature of the Declarant

STIPULATION RE: PRIVATE MEDIATION
o Parties agree that ____________________________________________(private mediator) shall mediate issues concerning custody and visitation of the following named children: ____________ _____________________________________________________________________________. o Parties stipulate to share all fees, _____% payable by Petitioner and _____% payable by Respondent __________________________________________, Petitioner __________________________________________, Respondent __________________________________________ Attorney for Petitioner __________________________________________ Attorney for Respondent

Date: _______________ Date: _______________ Date: _______________

Date: _______________

FL 13(a) Revised 1/1/03

Petition for Private Mediation

Local Rule 14.08 (H)