IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) ) Parent A's Name: Parent B's Name: This motion is filed by (check one) Parent A Parent B Both parties I ask the court to order the parties to participate in mediation through the Child Custody and Visitation Mediation Program. In support of this request, I state as follows: 1. 2. The parties have at least one minor child and cannot agree on custody or visitation. I understand that Alaska law restricts the court's ability to order mediation if domestic violence has occurred between the parties. I certify that: a. b. There is no domestic violence protective order currently in effect (no Alaska court order and no order issued in another state and filed in Alaska). In addition, one of the following is true (check one): No domestic violence has occurred between the parties. Domestic violence has occurred between the parties, but mediation should still be permitted because it is requested by the victim and the victim is signing this motion. CASE NO. MOTION FOR MEDIATION THROUGH CHILD CUSTODY & VISITATION MEDIATION PROGRAM 3. There is no cost to the parties for a limited amount of mediator time to mediate issues related to child custody and visitation. The mediator may agree to additional time or to mediate property matters at the parties' expense. American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 DR-405 (10/16)(cs) MOTION FOR MEDIATION Civ. R. 100 AS 25.20.080 AS 25.24.060 & .140 The party requesting mediation must sign below. If both parties are requesting mediation, then both parties must sign. If domestic violence has occurred between the parties, the court cannot order mediation unless the victim agrees (by signing this motion, by filing a response agreeing to mediation, or by agreeing at a hearing). Date Signature Print Name Mailing Address City State ZIP Daytime Phone Date Signature Print Name Mailing Address City If Motion Is Signed By Only One Party State ZIP Daytime Phone If this motion is signed by only one party, the party who signs it must mail a copy of the motion to the other party. If the other party is represented by an attorney, the copy must be mailed to the attorney instead of to the party. The party who signs the motion must complete the following certificate so the court knows that the other party has been sent a copy. CERTIFICATE OF SERVICE I certify that on a copy of this motion was mailed to (print name of party or attorney): Signature: Notice to Party Not Signing Motion You have a right to respond to this motion. Your response must be filed with the court and a copy mailed to the other party no later than ten days from the date shown in the above certificate of service. Your response must state whether you agree to mediation or do not agree. If you do not agree, describe why you believe mediation is not appropriate. Include the case number in your response. A response form (DR-406) is available from the court. If you fail to file a response, the court may grant the request for mediation and schedule a mediation session. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 DR-405 (10/16)(cs) MOTION FOR MEDIATION Civ. R. 100 AS 25.20.080 AS 25.24.060 & .140