AFFIDAVIT & ORDER TO WAIVE REQUIRED MEDIATION FORM This form is provided to people referred to mediation by Order of Judge or Court Commissioner who would like to be excused from mediation for one of the reasons provided by statute. You must be able to establish one of the reasons shown on the Affidavit & Order Waiving Mediation form to be excused from mediation. You may use this form to make your request. STEP 1: FILL OUT THE AFFIDAVIT FORM Type or print neatly. If you check a box that says there has been abuse but no court case is pending, or that there has been alcohol or drug abuse, or that your health or safety would be endangered by attending a mediation session, or that to attend mediation would cause undue hardship, you must explain why. Give specific facts about what has happened to you, who did it, and when. Put in facts such as whether or not you felt pain, did not consent, and feared for your safety. After completing the form, get your signature witnessed by a Notary Public. Make three additional copies. Keep a copy for yourself. STEP 2: FILE THE AFFIDAVIT File the original Affidavit in the Court Commissioner Center, Room 2000, Dane County Courthouse, 215 South Hamilton Street, Madison. There will be no filing fee. If the Court Commissioner believes a hearing is necessary, both parties will be notified by the Court. STEP 3: MAIL THE AFFIDAVIT Mail one copy of the Affidavit to the other party. If the Court Commissioner has a question about the other party having been notified of the Affidavit, the Commissioner will ask for further information or may require that legal service be obtained. STEP 4: THE COMMISSIONER'S RULING The Family Court Commissioner will review your Affidavit. If it meets the statutory requirements, mediation will be waived. A copy of the signed Order will be sent to both parties and Family Court Services by the Court. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF WISCONSIN CIRCUIT COURT, BRANCH ____ DANE COUNTY _______________________________ Petitioner _______________________________ Respondent AFFIDAVIT FOR WAIVING MEDIATION Case Number _____________ I, a party in this case, under oath, say upon personal knowledge, information and belief, that: 1. A dispute regarding physical placement and/or custody has been or will be referred to Dane County Family Court Services. I request a waiver of the required mediation session. The reason for this request is (check and explain all that apply): The other party has engaged in child abuse. There is a case involving child abuse and the case number is _______________________ The other party has engaged in interspousal battery or domestic abuse. There is a case involving domestic abuse and the case number is_____________________ The other party has engaged in child abuse, interspousal battery or domestic abuse. There is no pending case, but the abuse consists of: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ The other party has a significant problem with alcohol or drug abuse because: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Other evidence indicating that my health or safety will be endangered, or undue hardship caused, by attending the mediation session: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 2. Subscribed and sworn to before me this ______day of __________, 20 ___ , Notary Public, State of Wisconsin My Commission: ______________________ _________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com STATE OF WISCONSIN _______________________________ Petitioner _______________________________ Respondent CIRCUIT COURT, BRANCH ____ DANE COUNTY ORDER Case Number _____________ Based upon the above attached Affidavit, IT IS HEREBY ORDERED that the parties are not required to attend the private mediation session in the Dane County Family Court Services office. The parties shall attend the group session for individuals referred to that agency by Court order. Dated this ______________________day of _______________________, 20 _______ . BY THE COURT: ____________________________________ Court Commissioner Dane County, Wisconsin American LegalNet, Inc. www.FormsWorkFlow.com