P:\Internet\2017\family law\FCS\ME-804 Form Petition for Confidential Mediation 04-26-17.doc Page 1of 1 FL/E-ME-804 (Revised 04/26/17) Petition for Confidential Mediation Family Code 247247 3160-3186 Local Rule 5.16 Mandatory www.saccourt.ca.gov FL/E-ME-804 ATTORNEY, OR PARTY IF NO ATTORNEY: State Bar No.: Name: Address: City/State/Zip TELEPHONE NO.: ATTORNEY FOR: (Name) For Court Use Only SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: 3341 Power Inn Road MAILING ADDRESS: Same CITY, STATE, AND ZIP CODE: Sacramento, CA 95826 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CLAIMANT: PETITION FOR CONFIDENTIAL MEDIATION Case No.: 1. Do you have a current Restraining or Protective Order against the other party, or one that expired within the past 5 years? No Yes (If yes, you are not eligible for Confidential Mediation) 2. We would like assistance resolving issues related to: (Please check all that apply and provide a brief explanation) Custody Visitation Other I declare under penalty of perjury that the foregoing information is true and correct. Dated: // Signature of Declarant: Type or Print Name: PROOF OF SERVICE 1. I am at least 18 years old, am not a party to this case, and I am a resident of or employed in the county where service was completed. 2. I served a copy of this document by: Enclosing it in a sealed envelope and depositing it with the U.S. Postal Service with the postage fully prepaid. The envelope was addressed and mailed as follows: Name of person served: Address: Date mailed: Place of mailing (city and state): Personally delivering a copy to the person served, as follows: Name of person served: Date served: Time served: Address: I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Dated: // Signature of Person Doing the Serving: Type or Print Name: American LegalNet, Inc. www.FormsWorkFlow.com