IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: __________________________________, Petitioner and , Respondent Bar Code Label MOTION FOR REASSESSMENT OF FEE SHARING FOR PRIVATE MEDIATION The [ü one only] __ Petitioner or __ Respondent requests the following relief: 1. The Court entered an order for mediation on {date} ____________________________. 2. The order said that “Parties with combined income of $60,000 or over shall arrange to attend private mediation, in lieu of family mediation, and each party shall pay his/her equal share of the cost of that particular mediator’s fees for the mediation conference”. 3. The [ü one only] ___ Petitioner or ___ Respondent is unable to pay his/her equal share for said private mediation because: _________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ WHEREFORE [ü one only] __ Petitioner or __ Respondent prays this Court will find the [ü one only] __ Petitioner or __ Respondent shall be responsible for a greater share of the private mediation costs than that presently ordered. I HEREBY CERTIFY that a true and correct copy of the foregoing instrument has been furnished by U.S. mail service upon _________________________________________, at the address __________________________________________________________________, this _____ day of ______________________, 200__. ____________________________________ Signature of party Printed name _________________________ Address _____________________________ ____________________________________ City State Zip Telephone number ____________________ Law 1027 – rev. 10/2005 American LegalNet, Inc. www.USCourtForms.com MOTION FOR REASSESSMENT OF FEE SHARING FOR PRIVATE MEDIATION Page 2 Case No :_________________________ IF A NONLAWYER HELPED YOU FILL OUT THIS FORM TO GIVE TO THE JUDGE TO SIGN, THE NONLAWYER WHO HELPED YOU MUST FILL IN THE BLANKS BELOW: [! fill in all blanks] I, {full legal name and trade name of nonlawyer} ____________________________________, a nonlawyer, located at {street} ______________________________, {city}______________________, {state}______________, {phone}_______________, helped {Petitioner’s name} __________________, ____________________________________, who [ü one only] _____petitioner or _____ respondent, fill out this form. Law 1027 – rev. 10/2005 American LegalNet, Inc. www.USCourtForms.com