FOR CLERK’S USE ONLY Name of Person Filing: ________________________________________ Mailing Address: ________________________________________ City, State, Zip Code: ________________________________________ Daytime Phone Number: ________________________________________ Evening Phone Number: ________________________________________ ATLAS Number (if applicable) _____________________________________ Attorney Bar Number (if applicable) ________________________________ Petitioner Representing: Self Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY ___________________________________ Case Number:_____________________________ Petitioner/Plaintiff ___________________________________ Respondent/Defendant ALTERNATIVE DISPUTE RESOLUTION STATEMENT TO THE COURT A.R.C.P. 16(g)(2) Check appropriate box below: Petitioner’s Statement Respondent’s Statement Joint Statement (signed by both parties) Pursuant to the Arizona Rules of Family Law Procedure, we hereby state the following, under penalty of perjury: 1. The parties agree to participate in the following Alternative Dispute Resolution (ADR) process and: a. have selected the following ADR process: Arbitration Mediation Settlement Conference Other: ___________________________________________________________ b. The parties will use a private provider OR, The parties request a program provided through the Court. c. The person or company providing the ADR service is: ___________________________ ______________________________________________________________________ d. The parties expect to complete the ADR process by _____________________, ______. 2. The parties have been unable to agree on an ADR process. The Petitioner Respondent believe(s) that the following ADR process would be appropriate: ___________________________________. The Petitioner Respondent request(s) a conference to discuss ADR. The Petitioner Respondent believe(s) that an ADR process would not be appropriate for the following reason: _________________________________________ ______________________________________________________________________ ___________________________ Date ___________________________ Date 9/29/2010 __________________________________________________ Petitioner __________________________________________________ Respondent Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com