MED-150 (9/17)(cs) REQUEST FOR COURT-SPONSORED MINOR GUARDIANSHIP MEDIATION IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of ) DOB: ) DOB: ) DOB: ) DOB: ) Minors under the age of 18 years ) CASE NO. REQUEST FOR COURT-SPONSORED MINOR GUARDIANSHIP MEDIATION 1.I request a referral to the court-sponsored minor guardianship mediation program.2.I am the: Petitioner (or attorney) Parent (or attorney) GAL Guardian Other, my relationship to the minor(s) is: 3.matters if domestic violence has occurred between any of the parties. I certify that:a.There is no domestic violence protective order currently in effect (no Alaska courtorder and no order issued in another state and filed in Alaska), ANDb. No domestic violence has occurred between any of the partiesOR c. Domestic violence has occurred but the victim(s) has agreed to mediate.4. I consulted with all other legal parties and we all agree to make this referral (not required).5.The participants are available to mediate on (date) at am pm. 6.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. 7.Mediation should focus on the following areas or issues of concern: Date: Signature I certify that on a copy of this request was sent to: Type or Print Name Petitioner or Atty. Mailing Address Guardian Other City State ZIP Other By: Contact Telephone Number(s) Parent A or Atty. Parent B or Atty. American LegalNet, Inc. www.FormsWorkFlow.com