Choose a location ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: NOTICE OF CANCELLATION OF MEDIATION AND STATEMENT OF GOOD CAUSE (Local Rule 1501 et. seq., Family Code §3170) CASE NUMBER: Mediation date: Mediation time: Mediation place: Family Court Services 1100 Anacapa Street, Santa Barbara, CA 93101 201 S. Miller, Ste. 208, Santa Maria, CA 93454 Dept.: To: [Name of other parent and opposing counsel, if applicable] NOTICE: The Family Custody Services mediation appointment set for at [state your good cause reason(s)]: (date) (time) a.m./p.m. HAS BEEN CANCELLED for the following good cause reason(s) The cancellation of the mediation is based on good cause, or the Court may order monetary or other sanctions against the cancelling parent. DECLARATION OF COMPLIANCE WITH REQUIREMENT TO GIVE NOTICE OF THE CANCELLATION AND TO RESCHEDULE I, 1. 2. I am self- represented or I am an attorney and I represent Petitioner Respondent Other: Page 1 of 2 Mandatory Form SC-4017 [New Nov. 7, 2011] , declare [check the appropriate boxes]: NOTICE OF CANCELLATION OF MEDIATION AND STATEMENT OF GOOD CAUSE Local Rule 1501 et. seq., FC §3170 American LegalNet, Inc. www.FormsWorkFlow.com Insert Case Name: CASE NUMBER: 3. 4. 5. I understand that I am required to cooperate with the other parent and the attorney for the other parent, if retained, in order to: (a) schedule, (b) cancel or (c) reschedule a mediation appointment. I also understand that I can only cancel a mediation appointment for good cause. I have communicated with the other parent or the attorney for the other parent, if retained. We have agreed to reschedule the mediation appointment. I will serve on the other parent and file a new Notice of Mediation form (SC-4018). I have attempted to provide Notice of Cancellation and/or to reschedule the mediation appointment, but was not successful because: 6. [Statement of attempts to contact opposing party directly to cancel and reschedule, including details such as date, time, phone number(s) called, letters written, faxes or email sent.] See additional facts stated on separate paper labeled as Attachment 5 and attached to this Notice. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. DATED: SIGNED: Page 2 of 2 Mandatory Form SC-4017 [New Nov. 7, 2011] NOTICE OF CANCELLATION OF MEDIATION AND STATEMENT OF GOOD CAUSE Local Rule 1501 et. seq., FC §3170 American LegalNet, Inc. www.FormsWorkFlow.com