IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF ___________________ In the Matter of the Marriage of: Case No. _____________________________ Petitioner, a and REQUEST FOR MEDIATION Respondent. The parties to this case do not agree upon custody and/or parenting time. I, mother father, request that the court send us to a mediator. The contact address and contact telephone for each parent is: Mother: Father: Dated: Petitioner Respondent, Signature I certify that I mailed a true copy of this Request for Mediation to the other parent by placing a copy in a stamped envelope in the US Mail on_________________(insert date of mailing) addressed to mother father at the address listed above. Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to for assistance in preparing this form. Petitioner Respondent, Signature Submitted by: Petitioner Respondent, Print Name Address or Contact Address City, State, Zip Telephone or Contact Telephone REQUEST FOR MEDIATION - Page 1 of 1 6D-Z.MiscForms: 6H-Med-ReqVer03.doc (5/14) American LegalNet, Inc. www.FormsWorkFlow.com
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