Motion and Agreement to Mediate PC - 1002 REV. 7 /19 CONNECTICUT PROBATE COURTS Motion and Agreement to Mediate PC - 1002 Page 1 of 2 RECEIVED: Instructions: 1) Any party may use this form to request the court to refer a contested matter to a member of the mediation panel established by the Probate Court Administrator. All parties whose interests are affected must agree to mediate. 2)The motion must be filed in the court for the probate district having jurisdiction over the contestedmatter. 3)For more information, see Probate Court Rules of Procedure, rule 21.4)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number Estate of/In the Matter of Petitioner (Name, address and telephone number) Parties to Whom Notice of Mediation Should be Given: (Names and addresses) The p etitioner represent s that: 1)The above matter is contested.2)The parties whose interests are affected agree to mediation by a member of the mediation panel established by theProbate Court Administrator and have agreed in writing to an allocation of the mediation fees under C.G.S. section45a-106a(e) or 45a-107(k).3)The parties have selected the following mediator from the mediation panel: American LegalNet, Inc. www.FormsWorkFlow.com Motion and Agreement to Mediate PC - 1002 REV. 7 /19 CONNECTICUT PROBATE COURTS Estate of/In the Matter of Motion and Agreement to Mediate PC - 1002 Page 2 of 2 4) The issues that will be the subject of mediation are summarized below: WHEREFORE the petitioner requests that the court refer the above matter to a member of the mediation panel for mediation as agreed by the parties. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Title Type or Print Name Date By signing below, the parties whose interests are affected agree to mediate the contested issues and have agreed in writing to an allocation of mediation fees. Signature Signature Type or Print Name Type or Print Name Date Date Signature Signature Type or Print Name Type or Print Name Date Date Signature Signature Type or Print Name Type or Print Name Date Date American LegalNet, Inc. www.FormsWorkFlow.com