Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY REGARDING THE MATTER OF: SUPERIOR COURT CASE NO: __________________ ____________________________ Petitioner and REQUEST FOR MEDIATION WHEN THERE IS A CURRENT CHILD CUSTODY/PARENTING TIME ACTION BEFORE THE COURT: _____________________________ Respondent Pre-Decree Post-Decree Paternity (Post Judgment) If a Spanish-speaking mediator is required please check. (Si necesita un mediador que habla español, favor de indicarlo aquí.) There is a controversy or dispute between the parties concerning child custody and/or parenting time and there is a current child custody/parenting time action pending before the court. Mediation is requested by the Petitioner Respondent. Have the parties previous participated in Mediation? Yes No If yes, state where and when: ____________________________________________________________________ This mediation request pertains to the following minor child(ren): _______________________________________ Child’s name and age _______________________________________ Child’s name and age _______________________________________ Child’s name and age _______________________________________ Child’s name and age Describe what you would like to accomplish in mediation. Be brief and specific. If you have a dispute, the disagreement(s) must involve the custody and/or parenting time of your minor children. Financial and enforcement issues cannot be mediated. (Attach additional pages with the case number, if necessary). _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 1 of 2 mediation-request.form CC0178 Revised 1.3.08 American LegalNet, Inc. www.FormsWorkflow.com Note: Both parties should complete the mandatory Domestic Relations Education on Children’s Issues course (parent education) prior to mediation in pre-decree and in paternity cases in which there are no permanent orders for custody and/or parenting time. After you pay the course fee at the Clerk of the Superior Court, you may register for the parent education class at: http://www.sc.pima.gov/fccc/parented or by calling (520) 243-4949. In post-decree cases and in paternity cases where parties are requesting a modification of custody and/or parenting time, parent education will be required prior to mediation only upon the order of the assigned Judge. Petitioner Respondent has* has* has not attended the Domestic Relations Education on Children’s Issues Course. has not attended the Domestic Relations Education on Children’s Issues Course. (* attach a copy of your proof of attendance certificate) ______________ DATE ____________________________________________________________ Signature of : Petitioner Respondent OR Attorney for: Petitioner Respondent NAME AND ADDRESS OF THE PARTIES (PLEASE PRINT) _______________________________________ Petitioner’s Name _______________________________________ Respondent’s Name ________________________________________ Mailing Address _______________________________________ Mailing Address ________________________________________ City, State and Zip Code _______________________________________ City, State and Zip Code ________________________________________ Daytime or Message Phone _______________________________________ Daytime or Message Phone ________________________________________ Attorney for Petitioner (Please Print) _______________________________________ Attorney for Respondent (Please Print) FILE THE ORIGINAL REQUEST WITH THE CLERK OF THE SUPERIOR COURT AND MAIL OR DELIVER A COPY OF THIS REQUEST TO: Conciliation Court Petitioner Respondent Attorney for Petitioner Attorney for Respondent 2 of 2 mediation-request.form CC0178 Revised 1.3.08 American LegalNet, Inc. www.FormsWorkflow.com