SUPERIOR COURT OF CALIFORNIA, COUNTY OF MERCED FAMILY COURT SERVICES Attorney or Party without Attorney (Name, state bar, and address): Telephone No: (209) FOR COURT USE ONLY Fax No: (209) Attorney for: (Name) SUPERIOR COURT OF CALIFORNIA, COUNTY OF MERCED STREET ADDRESS: 2260 N Street MAILING ADDRESS: 627 W. 21ST Street CITY AND ZIP CODE: Merced, CA 95340 Branch Name: Family Law Division, Courtroom 6 REQUEST FOR TELEPHONIC MEDIATION Case Number: F I, , submit this written request for the Court’s approval to conduct the Mediation currently scheduled for ______________ by a telephonic appearance. I understand that if granted, Mediation shall be conducted by the Mediator and I shall be advised of the possible Six (6) hour period in which the Mediator shall be able to contact me. The telephone number provided below is the number that I can be reached at throughout that time period. I am requested to participate by telephone for Mediation for the following reasons: I, , submit that this is a true and correct telephone number of where I can be reached for the purpose of Court contact and Mediation: Telephone Number including area code Date: ______________________ ______________________________________________________ Signature of Party The request for Telephonic Mediation is hereby: Date: ________________________ GRANTED DENIED ________________________________________________ Judge of the Superior Court Gave party info/Left msg for party OR Gave copy to party/attorney: by (Date) (Court Clerk’s Inintals) American LegalNet, Inc. www.FormsWorkFlow.com