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Petition For Private Mediation Form. This is a California form and can be use in Sacramento Local County.
FL/E-LP-601 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NO: For Court Use Only ATTORNEY FOR: (Name) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: 3341 Power Inn Road MAILING ADDRESS: Same CITY AND ZIP CODE: Sacramento, CA 95826 PETIT1ONER/PLAINTIFF: RESPONDENT/DEFENDANT: PETITION FOR PRIVATE MEDIATION Local Rules 14.08.01 CASE NUMBER: 1. Date of last Mediation Report: ______/__________/___________. 2. Do you currently have an appointment set for FCS mediation? If so, when? ______/_______/_________. 3. Do you currently have an appointment set for FCS mediation? If so, when? ______/_______/_________. 4. Have you been to private mediation before? If so, when? ______/_______/_________. 5. Do you have a current Domestic Violence Restraining Order? Yes (attach copy) No 6. Do you have an existing court order for custody/visitation? Yes (attach copy) No 7. Issues to be mediated concern custody and visitation of the following named child(ren): ____________ _________________________________________________________________________________________ 8. Request that one of the following private mediators be appointed: __________________________________________________________________________________________ 9. Declarant shall advance the cost of private mediation subject to the court reserving the right to order reimbursement from the other party. Any information I have provided above and any attachment to this Petition is furnished in good faith in the hope of settling the controversy. I declare under penalty of perjury under the laws of the State of California that the foregoing information is true and correct. Date: _____/________/________ ___________________________________ Signature of the Declarant STIPULATION RE: PRIVATE MEDIATION Parties agree that ________________________________________ (private mediator) shall mediate issues Concerning custody and visitation of the following named children: ______________________________________ _____________________________________________________________________________________________ Parties stipulate to share all fares, _______% payable by Petitioner and ________% payable by Respondent. Date: _______________ __________________________________________, Petitioner Date: _______________ __________________________________________, Respondent Date: _______________ __________________________________________ Attorney for Petitioner Date: _______________ __________________________________________ Attorney for Respondent Page 1 of 2 FL/E-LP-601 (Revised 12/2/2009) Petition for Private Mediation Local Rule14.16.01 Mandatory www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL/E-LP-601 THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF SACRAMENTO Petitioner _____________________________ Case No. __________________ Respondent ___________________________ PROOF OF SERVICE 1. I am over the age of 18 years and am not a party to this cause. I am a resident of or employed in the county where the mailing occurred. My residence or business address is: __________________________________________________________________ __________________________________________________________________ 2. I served a copy of the following document(s): __________________________________________________________________ __________________________________________________________________ By placing a true copy of each document in the United States mail in a sealed envelope with postage fully prepared as follows: a. Date of deposit: b. Place of deposit (city and state): c. Addresses as follows: By personally delivering copies to the person served as follows: Person served (name): Time: Address: Date: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ____________________________ __________________________ (Type or print name) (Signature) Page 2 of 2 FL/E-LP-601 (Revised 12/2/2009) Petition for Private Mediation Local Rule14.16.01 Mandatory www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com
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