ATTORNEY OR PARTY WITHOUT AN ATTORNEY (NAME, ADDRESS & PHONE) FOR COURT USE ONLY ATTORNEY FOR: SUPERIOR COURT OF CALIFORNIA, COUNTY OF AMADOR STREET ADDRESS: 500 ARGONAUT LANE CITY & ZIP CODE: JACKSON, 95642 PETITIONER: RESPONDENT: CASE NO.: FAMILY LAW SETTLEMENT CONFERENCE STATEMENT 1. Parties (a) Attorney for (b) (c) 2. 3. Nature of Case General Information Petitioner Respondent Joined Party Self-represented Respondent Self-represented Petitioner Other (explain) ___________________________________ Dissolution Legal Separation (a) Date of Marriage/Partnership: _______________________________________________ Date of Separation: _______________________________________________________ (b) Minor Child/ren and ages: ______________________ ______________________ ______________________ _______ _______ _______ ______________________ ______________________ ______________________ Final Yes Yes _______ _______ _______ (c) Service of Declarations of Disclosure Preliminary Petitioner Yes No Respondent Yes No 4. No No Issues in Agreement (Check all applicable boxes) Yes Date of Stipulation and/or Order (if applicable): (a) Child Custody (b) Child Support (c) Spousal Support (d) Attorney Fees (e) Paternity (f) Property Division ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Page 1 American LegalNet, Inc. www.FormsWorkFlow.com FAMILY LAW SETTLEMENT CONFERENCE STATEMENT (New 09/17/2012) FCS-052 If there is a property agreement, please specify issues agreed upon (e.g.: personal property, residence/real property, debts): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 5. Issues in Dispute (a) Child Custody (Check applicable box and briefly state position.) Yes Party's statement of contention: _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (b) Child Support _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (c) Spousal Support _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (d) Property Division (Assets & Debts) _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 5(d) For any property items in dispute, forms FL-160 and FL-161 must be fully completed and attached to this statement. (e) Attorney Fees _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (f) Paternity of Minor Children _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ FAMILY LAW SETTLEMENT CONFERENCE STATEMENT (New 09/17/2012) FCS-052 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 6. Other Issues in Dispute Specify: ____________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 7. Trial Estimate: _______________ Hour(s) or _______________ Day(s) DATED: __________________________________________ Attorney for or self-represented Petitioner Respondent Joined Party Proof of Service by Mail I declare I am over 18 years of age, not a party to this action. I am a resident of or employed in the county where the mailing took place. My residence or business address is: _____________________________________________________ ______________________________________________________ On the date below, I served a completed copy of this document by: depositing the sealed envelope with the United States Postal Service with the postage fully prepaid or placing the envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service in a sealed envelope with postage fully prepaid. The envelope was addressed and mailed as follows: Name of person served: ___________________________________________ ____________________________________________ I declare, under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct. DATE: Signature of Person Mailing:_______________________________________ Print Name of Person Mailing:______________________________________ Address of person served: ____________________________________________ FAMILY LAW SETTLEMENT CONFERENCE STATEMENT (New 09/17/2012) FCS-052 American LegalNet, Inc. www.FormsWorkFlow.com Page 3