Motion and Agreement to Mediate PC-1002 REV. 1/17 CONNECTICUT PROBATE COURTS RECEIVED: Instructions: 1) A party may use this form to request the court to refer a contested matter to a member of the mediation panel established by the Probate Court Administrator. All parties whose interests are affected must agree to mediate. 2) The motion shall be filed in the Probate Court having jurisdiction over the contested matter. 3) For more information, see Probate Court Regulations, section 22. 4) Type or print the form in ink. Use an additional sheet or Second Sheet, PC-180, if more space is needed. District Number Probate Court Name Estate of/In the Matter of Petitioner (List name and address.) Names and Addresses of Parties to Whom Notice of Mediation Should be Given: THE PETITIONER REPRESENTS THAT: 1) The above matter is contested. 2) The parties whose interests are affected agree to mediation by a member of the mediation panel established by the Probate Court Administrator under the Probate Court Regulations, section 22, and have agreed in writing to an allocation of the mediation fees under 45a-106a (e) or 45a-107 (k). 3) The parties have selected the following mediator from the mediation panel:______________________________. 4) The issues that will be the subject of mediation are summarized below: Motion and Agreement to Mediate American LegalNet, Inc. www.FormsWorkFlow.com PC-1002 Page 1 of 2 Motion and Agreement to Mediate PC-1002 REV. 1/17 CONNECTICUT PROBATE COURTS THE PETITIONER REQUESTS THAT: The court refer the above matter to a member of the mediation panel for mediation as agreed by the parties. The representations made in this motion are made under the penalty of false statement. Signature of Petitioner Title Type or Print Name Date By signing below, the parties whose interests are affected agree to mediate the contested issues and have agreed in writing to an allocation of mediation fees. Signature Type or Print Name Date Signature Type or Print Name Date Signature Type or Print Name Date Signature Type or Print Name Date Signature Type or Print Name Date Signature Type or Print Name Date Motion and Agreement to Mediate American LegalNet, Inc. www.FormsWorkFlow.com PC-1002 Page 2 of 2