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Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY REGARDING THE MATTER OF: ____________________________ Petitioner and ____________________________ Respondent SUPERIOR COURT CASE NO: __________________ REQUEST FOR POST-DECREE OR POST JUDGMENT MEDIATION: NO PENDING CUSTODY AND/OR PARENTING TIME ACTION BEFORE THE COURT: Post-Decree Post Judgment (Paternity) If a Spanish-speaking mediator is required please check. (Si necesita un mediador que habla español, favor de indicarlo aquí.) NOTICE TO PARTY WHO DID NOT FILE THE REQUEST FOR MEDIATION You have 20 days from the date you are served with this request to file a response. Your response must be filed with the Clerk of the Court, Arizona Superior Court, Pima County, 110 W. Congress, Tucson, AZ 85701. A copy of your response must be sent to the assigned Judge and to the party filing the request. The Petitioner or Respondent states: There is a dispute between the parties regarding custody or parenting time and the parties have agreed in writing in the most recent parenting plan or by stipulation or were ordered to seek mediation as a method of resolving disputes prior to petitioning the Court for a hearing, and the parties are not willing to voluntarily agree to attend mediation at the Conciliation Court, AND/OR There is an order adjudicating paternity, but no custody or parenting time orders entered in a paternity action, AND/OR It has been more than 1 year since the most recent court-ordered child custody/parenting plan, and there is a significant change in a parent's or child(ren)'s circumstances which would warrant a change in the existing orders, and all parties are not willing to voluntarily agree to attend mediation. Have the parties previously participated in Mediation? yes no If yes, state where and when: _______________________________________________________. 1 of 2 mediation-request.form CC0473 Revised 1.3.08 American LegalNet, Inc. www.FormsWorkflow.com This mediation request pertains to the following minor child(ren): _______________________________________ Child's name and age _______________________________________ Child's name and age _______________________________________ Child's name and age _______________________________________ Child's name and age Describe what you would like to accomplish in mediation. Be brief and specific. If you have a dispute, the disagreement(s) must involve the custody and/or parenting time of your minor children. Financial and enforcement issues cannot be mediated. (Attach additional pages with the case number on each if needed). _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ______________ Date: ____________________________________________________________ Signature of : Petitioner Respondent OR Attorney for: Petitioner Respondent NAME AND ADDRESS OF THE PARTIES (PLEASE PRINT): _______________________________________ Petitioner's Name ________________________________________ Mailing Address ________________________________________ City, State and Zip Code ________________________________________ Daytime or Message Phone ________________________________________ Attorney for Petitioner (Please Print) _______________________________________ Respondent's Name _______________________________________ Mailing Address _______________________________________ City, State and Zip Code _______________________________________ Daytime or Message Phone _______________________________________ Attorney for Respondent (Please Print) FILE THE ORIGINAL REQUEST WITH THE CLERK OF THE SUPERIOR COURT AND SERVE A COPY TO THE OTHER PARTY. FILE PROOF OF SERVICE WITH THE CLERK OF THE SUPERIOR COURT. MAIL OR DELIVER A COPY TO: Conciliation Court Petitioner Respondent Attorney for Petitioner Attorney for Respondent 2 of 2 mediation-request.form CC0473 Revised 1.3.08 American LegalNet, Inc. www.FormsWorkflow.com