Name, Address, Telephone # State Bar # FOR the USE of the ALONE COURT Attorney for:: SUPERIOR COURT OF CALIFORNIA, COUNTY OF YOLO 1000 Main Street Woodland, California, 95695 530/406-6704 Plaintiff(s): Case Number: Defendant(s): STIPULATION FOR REFERRAL TO FAMILY LAW MEDIATION COUNSELOR IT IS HEREBY STIPULATED by the parties: 1. The matter is referred to a Court appointed mediation counselor to undertake a mediation counseling program. Areas of dispute: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 2. The Court and the parties waive their right the confidentiality as to any communication made to the counselor during this mediation. All mediation is at the expense of the parties. ________________________________ Signature of Petitioner ________________________________ Petitioner (Print) ________________________________ Address, City, Zip Code ________________________________ Telephone ________________________________ Attorney for the Petitioner ________________________________ Address, City, Zip Code ________________________________ Telephone ______________________________ Signature of Respondent ______________________________ Respondent (Print) ______________________________ Address, City, Zip Code ______________________________ Telephone ______________________________ Attorney for Respondent ______________________________ Address, City, Zip Code ______________________________ Telephone Preferred Counseling Agency ________________________________________________________________ It is ordered that the matter be set for mediation and that the counselor's report shall be filed and a copy provided to each attorney on before: _________________ Date:_________________ Distribution: Court file ­ original Petitioner/Attorney ­ 1 copy Respondent/Attorney ­ 1 copy Mediator ­ 1 copy Rev.6/16 ___________________________________________________ JUDGE YOCV 0220 Stipulation for Referral to Family Law Mediation Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com