MED-200 (6/15)(cs) REQUEST FOR COURT-SPONSORED CINA MEDIATION IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of ) DOB: ) ) DOB: ) ) DOB: ) ) DOB: ) CASE NO. Minors Under the Age of Eighteen (18) Years ) REQUEST FOR COURT-SPONSORED CINA MEDIATION 1.I request a referral for CINA Mediation.2.I am the: OCS Worker GAL AAG Mother (or attorney) Father (or attorney) Tribal Representative Indian Custodian (or attorney) Other legal party 3. I consulted with all other legal parties and we all agree to make this referral (not required). 4.The participants are available to mediate on (date) at am pm or (date) at am pm. 5.People who should participate in the mediation are: Name Relationship Phone(s) and Email address NOTE: If you need to add more names, please attach an additional sheet. 6.Mediation should focus on the following areas or issues of concern: Date Signature Print Name I certify that on a copy of this request was sent to: Mailing Address Mother Father OCS AAG Indian Custodian Tribe GAL City State ZIP PD CASA Fam. Case Svcs. Coor. Other Contact Telephone Number(s) By: American LegalNet, Inc. www.FormsWorkFlow.com