ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 W. Main Street El Centro, CA 92243 PETITIONER: RESPONDENT: STIPULATION FOR MEDIATION CASE NUMBER: 1. Provide any of the following case numbers: Family Law: _____________________ Domestic Violence: _______________ Family Support: _______________________ Uniform Parentage Action:______________ 2. A dispute exists between the above named parties concerning (check all that apply and provide a brief explanation): Custody Visitation Other 3. Date of last Mediation Report: ______/______/______. 4. Do you have a current Domestic Violence Restraining Order? Yes (If yes, attach copy) No Please provide the following information. (Post Office Box if Domestic Violence is an issue.) _________________________________________________________________________________ _________________________________________________________________________________ PETITIONER'S INFORMATION: RESPONDENT'S INFORMATION: Name: Mailing Address: City State/Zip: Home Phone: Relationship to child: Language: Attorney: Name: Mailing Address: City State/Zip: Home Phone: Relationship to child: Language: Attorney: Work Phone: Work Phone: 5. Any information I have provided above and any attachment to this request is furnished in good faith in the hope of settling the dispute. I declare under penalty of perjury that the foregoing is true and correct. ___________________________________ ______________________________________ PETITIONER SIGNATURE AND DATE RESPONDENT- SIGNATURE AND DATE 6. Notice of Mediation Appointment: Superior Court, Family Law, Clerk's Office 939 Main Street, Lower Level, El Centro, CA ___________________________________ CLERK SIGNATURE Date: _________ Time: ___________ Form Approved for Optional Use FL-05 (Adopted 07/01/07, Revised 07/01/08, 01/01/11, 01/01/12, 01/01/13, 01/01/15) imperial.courts.ca.gov STIPULATION FOR MEDIATION American LegalNet, Inc. www.FormsWorkFlow.com