Superior Court of California County of Sacramento Sitting as the Juvenile Court IN RE THE MATTER OF: ____________________________________ A Child(ren) (requesting party) ) ) ) ) Case No. _______________ Request For Mediation I _____________________ request a Mediation Conference for the following issue(s): _______________________________________________________________________ _______________________________________________________________________ Date: _____________________ __________________________ Signature Telephone Number: __________ (Date) (Time) Mediation Conference is set for ____________________ at ____________ in Room 104. at the William R. Ridgeway Family Relations Courthouse, Family Court Services , located on the 1rd floor . It is requested the following parties attend the Mediation Conference: Who DHHS Social Worker Child/SCA Social Worker Mother Father Other Parent/Guardian Other Parent/Guardian Counsel of Record Deputy County Counsel Name Telephone Number Requesting party has notified attorneys of record of the request for mediation: Party Represented Counsel Appointed/Retained & telephone Number Informed & date Agree Object Mother's Attorney on Father's Attorney on Child's Attorney on Other Attorney on Other Attorney on County Counsel on All counsel shall have the opportunity to review any mediation agreements and agree or disagree to the content, prior to the agreement's submission to the court. The document shall be retained in Family Court Services for two (2) working days for this purpose. Case Name: __________________________ Court Number: _______________________ JC\E-309 (01.03) Request for Mediation Date Submitted: ___________ American LegalNet, Inc. www.USCourtForms.com