ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 Main Street El Centro, CA 92243 PETITIONER: RESPONDENT: ADVANCE MEDIATION FORM CASE NUMBER: 1. Provide any of the following case numbers: Family Law: _____________________ Domestic Violence: _______________ Family Support: _______________________ Uniform Parentage Action:______________ 2. A Controversy exists between the above named parties concerning (check all that apply and provide a brief explanation): Custody Visitation Other ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Date of last Mediation Report: ______/______/______. 4. Do you have a current Domestic Violence Restraining Order? Yes (If yes, attach copy) Date: _________ Time: ___________ No 5. Notice of Mediation Appointment: Superior Court, Access Center 939 Main Street, Lower Level, El Centro, CA Please provide the following information. (Post Office Box if Domestic Violence is an issue.) PETITIONER’S INFORMATION: RESPONDENT’S INFORMATION: Name: Mailing Address: City State/Zip: Home Phone: Relationship to child: Language: Attorney: Work Phone: Name: Mailing Address: City State/Zip: Home Phone: Relationship to child: Language: Attorney: Work Phone: 6. Any information I have provided above and any attachment to this request is furnished in good faith in the hope of settling the controversy. I declare under penalty of perjury that the foregoing is true and correct. ___________________________________ ______________________________________ PETITIONER SIGNATURE AND DATE RESPONDENT- SIGNATURE AND DATE Form Approved for Optional Use FL-05 (Adopted 07/01/07, Revised 07/01/08, Revised 01/01/11) American LegalNet, Inc. www.FormsWorkFlow.com