ALA FL-002 - Attachment ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, ALAMEDA COUNTY STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER: CASE NUMBER: CONSENT TO SERVE AND CERTIFICATION OF PRIVATE CHILD CUSTODY RECOMMENDING MEDIATOR 1. My name is 2. Pursuant to the order of court rendered on (date) recommending mediator in the above entitled action. , I hereby consent to serve as the private child custody 3. I agree to conduct the mediation in accordance with and shall comply with Family Code §§216, 1815 and 3160 through 3188, and the applicable provisions of California Rules of Court. I shall submit to the Court a written report and recommendations as to custody and/or visitation, and may submit such other recommendations as are authorized by Family Code §3183. I will be impartial, maintain appropriate levels of confidentiality, and shall function at the request of the Court and pursuant to court order. CERTIFICATION I certify that I meet the minimum qualifications required of a counselor of conciliation as provided in Family Code § 1815 and that I meet the continuing education requirements specified in Family Code § 1816. Date: _________________________________________________________ (SIGNATURE OF PRIVATE CHILD CUSTODY RECOMMENDING MEDIATOR) Page 5 of 5 Form Adopted for Mandatory Use Superior Court of California, County of Alameda ALA FL-002 ­ Attachment [New January 1, 2008] CONSENT TO SERVE AND CERTIFICATION OF PRIVATE CHILD CUSTODY RECOMMENDING MEDIATOR Fam. Code § 3164 American LegalNet, Inc. www.FormsWorkFlow.com