Request For Mediation Current Action Before The Court

Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY ______________________________________ Petitioner/Plaintiff and Case No. _________________ REQUEST FOR MEDIATION ______________________________________ Respondent/Defendant (Pre-decree/Judgment or stipulated post-decree/Judgment) There is a controversy or dispute between the parents concerning: child custody parenting time both (child custody and parenting time) and mediation is requested by the (Petitioner/Plaintiff) A Decree of Dissolution/Judgment of Paternity Presently there is (has) (Respondent/Defendant). (has not) been granted. Date of decree/Judgment: _____ is not a custody and/or parenting time action pending before the court. Yes No Has mediation been previously attempted? If so, where and when: _____________________________________________________________________________________________ Briefly and specifically describe the current disagreement and what you would like to accomplish in mediation: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 1 mediation-request.form Revised 5.18.05 American LegalNet, Inc. www.USCourtForms.com ______ If a Spanish speaking mediator is required please check (Si necesita un mediador que habla espanol, favor de indicarlo aqui) RESPECTFULLY SUBMITTED THIS _____ DAY OF _______________, 20 ____ ___________________________________ and/or Signature of Plaintiff/Petitioner _________________________________ Respondent/Defendant This request pertains to (number) ____ minor child(ren), age(s) _________, _________, _________, _________ Petitioner/Plaintiff: _____________________________________ Name _____________________________________ Mailing Address _____________________________________ City, State and Zip Code _____________________________________ Daytime or Message Phone _____________________________________ Name of Attorney for Petitioner/Plaintiff Respondent/Defendant: _____________________________________ Name _____________________________________ Mailing Address _____________________________________ City, State, and Zip Code _____________________________________ Daytime or Message Phone _____________________________________ Name of Attorney for Respondent/Defendant 2 mediation-request.form Revised 5.18.05 American LegalNet, Inc. www.USCourtForms.com