ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NO: For Court Use Only ATTORNEY FOR: (Name) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO 3341 Power Inn Road STREET ADDRESS: Same MAILING ADDRESS: CITY AND ZIP CODE: Sacramento, CA 95826 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: PETITION FOR PRIVATE MEDIATION Local Rules 14.08(H) 1. Date of last Mediation Report: 2. Do you currently have an appointment set for FCS mediation? If so, when: 3. Have you been to Family Court Services before? If so, when? 4. Have you been to private mediation before? If so, when? 5. Do you have a current Domestic Violence Restraining Order? Yes (attach copy) No 6. Do you have an existing court order for custody/visitation? Yes (attach copy) No 7. Issues to be mediated concern custody and visitation of the following named child(ren): 8. Request that one of the following private mediators be appointed: 9. Declarant shall advance the cost of private mediation subject to the court reserving the right to order reimbursement from the other party. Any information I have provided above and any attachment to this Petition is furnished in good faith in the hope of settling the controversy. I declare under penalty of perjury under the laws of the State of California that the foregoing information is true and correct. Date: Signature of the Declarant STIPULATION RE: PRIVATE MEDIATION Parties agree that (private mediator) shall mediate issues concerning custody and visitation of the following named children: Parties stipulate to share all fees, % payable by Petitioner and . % payable by Respondent Date: , Petitioner Date: , Respondent Date: Attorney for Petitioner Date: Attorney for Respondent FL 13(a) Revised 1/1/03 Petition for Private Mediation Local Rule 14.08(H) American LegalNet, Inc. www.USCourtForms.com THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF SACRAMENTO Petitioner Case No. Respondent PROOF OF SERVICE 1. I am over the age of 18 years and am not a party to this cause. I am a resident of or employed in the county where the mailing occurred. My residence or business address is: 2. I served a copy of the following document(s): By placing a true copy of each document in the United States mail in a sealed envelope with postage fully prepared as follows: a. Date of deposit: b. Place of deposit (city and state): c. Addressed as follows: By personally delivering copies to the person served as follows: Person served (name): Time: Address: Date: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (Type or print name) (Signature) American LegalNet, Inc. www.USCourtForms.com