Request For Mediation

FOR CLERK'S USE ONLY Name of Person Filing Document: _________________________________ Mailing Address: _________________________________ City, State, Zip Code: _________________________________ Day/Evening Phone Number: _________________________________ Attorney Bar Number (if applicable): _________________________________ Representing: Self, Without a Lawyer, OR Attorney for _______________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA IN AND FOR THE COUNTY OF MOHAVE In re the Matter of: Case No. _______________________ ______________________________ (Name of Petitioner) REQUEST FOR MEDIATION AND ______________________________ (Name of Respondent) I, ___________________________, am requesting Mediation because there is a disagreement between the parents concerning legal decision making and/or visitation as follows: (examples: Need to modify parenting time; Need to work out holiday or vacation schedule; One parent is moving, etc.) NOTE: The Mediation Department cannot assist with issues regarding property or finances. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________ Date ______________________________________ Signature The person filing this Request for Mediation is sending a copy to the other party at this address: ___________________________________ ___________________________________ ___________________________________ on this date:_________________________ Revised: 1/1/2013 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA MOHAVE COUNTY ____________________________________ (Name of Petitioner) AND ____________________________________ (Name of Respondent) Case No: ________________________ ORDER FOR MEDIATION IT IS HEREBY ORDERED that as a result of the REQUEST FOR MEDIATION, the parties are referred to Conciliation Court for mediation and that the parties participate and cooperate in the mediation process. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DATE:__________________________ ______________________________________ Judge/Commissioner of the Superior Court cc: Mediation Revised: 1/1/2013 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com