Superior Court of California, County of Imperial ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): TELEPHONE
FOR COURT USE ONLY
ATTORNEY FOR (NAME):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL
STREET ADDRESS: MAILING ADDRESS:: CITY AND ZIP CODE:
PETITIONER/PLANTIFF: RESPONDENT/DEFENDANT: CLAIMANT:
ADVANCE MEDIATION FORM Family Code ยงยง 3160-3186
Case No.:
1.
Provide any of the following applicable case numbers: Family Law: _________________ Family Support: ________________ Domestic Violence: _____________ Other Family Law # _____________
2.
A Controversy exists between the above names parties concerning (check all that apply and provide brief explanation): Custody Visitation Other ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
3. Date of last Mediation Report: ________/ ________/ __________ 4. Do you have a current Domestic Violence Restraining Orders? Yes (If yes, attach a copy) No 5. Any information I have provided above and any attachment to this Petition is furnished is good faith in the hope of settling the controversy. I declare under penalty of perjury that the foregoing information is true and correct. Dated: ______/______/_____ _____________________________ Dated: _____/______/______ _____________________________
ORDER: Mediation of the controversy is ordered. Dated: _____/____/_____
Form Approved for Optional Use FL-05 (Adopted 7/1/07; Revised 7/1/08)
_________________________________________ Judge of the Superior Court of California, County of Imperial