ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY TELEPHONE NO.: ATTORNEY FOR (Name): FAX NO. (Optional) Amador Superior Court 500 Argonaut Lane Jackson, CA 95642 www.amadorcourt.org IN THE MATTER OF: CASE NUMBER: REQUEST FOR REFERRAL TO JUVENILE COURT MEDIATION 1. Childs/s name(s): 2. The child is the subject of a petition that has been filed in this court under Welfare and Institutions Code section 300. 3. Petitioner will be requesting the court terminate jurisdiction of the petition filed under Welfare and Institutions Code section 300. 4. Upon the termination of jurisdiction by the juvenile court, petitioner will be requesting a Custody Order Final Judgment - be issued pursuant to Welfare and Institutions Code section 302(d). A final judgment may include: custody, visitation (parenting time), holiday schedule and parentage orders. 5. Petitioner requests the following parents/guardians be ordered to participate in juvenile court mediation. a. Name: b. Name: c. Name: Mother Mother Mother father father father guardian guardian guardian 6. I declare under penalty of perjury under the laws of the State of California that the information in this form is true and correct to the best of my knowledge. Dated: Type of print name Signature Amador Court _________________________________________________________________________________________ Adoption for Mandatory Use 03/20/2017 REQUEST FOR REFERRAL TO JUVENILE COURT MEDIATION JVDP-032 American LegalNet, Inc. www.FormsWorkFlow.com