SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER Form Adopted for Optional Usewww.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-FCS007 Effective 01-01-2019 ATTORNEY, OR PARTY IF NO ATTORNEY: (Name and Address): TELEPHONE NO.: FOR COURT USE ONLY Superior Court of California, County of Placer 10820 Justice Center Drive 2501 N. Lake Blvd. P. O. Box 619072 P.O. Box 5669 Roseville, CA 95661 - 9072 Tahoe City , CA 96145 Petitioner : Respondent: PETITION FOR CONFIDENTIAL CHILD CUSTODY MEDIATION CASE NUMBER: We, the petitioner and respondent (or other party), do not agree on issues of legal custody (decision making) and/or parenting time but we do agree to participate in mediation. We request child custody mediation for the issues described below: Petitioner Respondent Mailing Address Mailing Address City, State, Zip Code City, State, Zip Code Telephone Number / Message Number Telephone Number / Message Number Email Address Email Address Attorney222s Name Attorney222s Name Attorney222s Full Address Attorney222s Full Address Attorney222s Telephone Number Attorney222s Telephone Number Attorney222s Email Address Attorney222s Email Address Petitioner222s Signature Respondent222s Signature Signature of Counsel for Petitioner Signature of Counsel for Respondent American LegalNet, Inc. www.FormsWorkFlow.com