ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address) : TELEPHONE NO.: FOR COURT USE ONLY FAX NO.(Optional): E-MAIL ADDRESS (Optional) : ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF MERCED STREET ADDRESS: 2260 "N" Street MAILING ADDRESS: 627 West 21st Street CITY AND ZIP CODE: MERCED, CALIFORNIA 95340 BRANCH NAME: FAMILY LAW FACILITY PETITIONER: RESPONDENT: CLAIMANT: EX-PARTE REQUEST AND ORDER RE: DISQUALIFICATION OF MEDIATOR OR EVALUATOR 1) I am the Petitioner 2) I move to disqualify the following reasons: Respondent Other CASE NUMBER: in the action herein. to act as Mediator or Evaluator in the matter herein for a) Conflict of Interest. Please state all facts which support this claim. You may attach additional pages as needed. b) Other. Please state all facts which support this claim. You may attach additional pages as needed. Dated: MER-0015 Rev. 04/02/2007 PETITIONER/RESPONDENT/OTHER EX-PARTE REQUEST AND ORDER RE: DISQUALIFICATION OF MEDIATOR OR EVALUATOR American LegalNet, Inc. www.FormsWorkFlow.com Order The Court hereby: Denies the Order requested: Grants the Order requested: It is so ordered. Dated: JUDGE/COMMISSIONER OF THE SUPERIOR COURT PROOF OF SERVICE BY MAIL On I served the above Ex-Parte Request and Order Re: Disqualification of Mediator or Evaluator by depositing a copy thereof, enclosed in a sealed envelope, with postage prepaid, in the United States mail to the following parties and/or their attorney of record at the following addresses: At the time of service, I was at least 18 years of age and not a party to the action. My address is: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and this declaration is executed on , at , California. MER-0015 Rev. 04/02/2007 EX-PARTE REQUEST AND ORDER RE: DISQUALIFICATION OF MEDIATOR OR EVALUATOR American LegalNet, Inc. www.FormsWorkFlow.com