Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: ATLAS Number: Lawyer's Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Name of Petitioner Case Number: ATLAS Number: (if applicable) Assigned to Judge: Name of Respondent JOINT REQUEST FOR PRE-DECREE MEDIATION We do not agree about the custody and/or parenting time issues involving our child(ren), but we do agree to participate in mediation. We ask that the Court refer this matter to Conciliation Services for mediation of the issues, based on the following: 1. Check one box only. Divorce or Separation Pending: My spouse or I have filed papers with the Court for divorce or legal separation. No final orders about legal decision making (custody) or parenting time have been entered by the Judge. (file petition and order with the assigned Judge.) Paternity Order Pending: One of the parties has filed papers with this court to decide who the father of our child(ren) is, and to decide legal decision making (custody) and parenting time. Other: (please describe) 2. Check one box only. We have not participated in mediation before OR We have participated in mediation before. If so, when and where? When: When: Where: Where: 3. Describe the disagreement. Be brief and specific. (The disagreement must involve the custody and/or parenting time of your minor child(ren)): Date Signature of Petitioner Date Signature of Respondent Address: City, State, Zip Code: Telephone Number: Address: City, State, Zip Code: Telephone Number: Petitioner's Attorney (if applicable) Respondent's Attorney (if applicable) NOTICE TO BOTH PARTIES: After this Joint Request is filed, Conciliation Services will mail an "Order to Attend Mediation" to both parties. WARNING: THERE MAY BE A $200 FEE FOR FAILURE TO ATTEND! ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PME DRADM12f-062916 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com