MEDIATION & DIVERSION SERVICES PIP REQUEST 800 East Twiggs Street, Room 208, Tampa, FL 33602-4024 (813) 272-5642 phone (813) 301-3706 fax MEDIATION REQUEST *Please Note* To Process Your Request for Mediation To Be Scheduled You Must Supply Our Office With The Date That The PIP Order was signed by the Judge. Your Name: Date: Case No.: Div: Phone: CASE STYLE (As originally filed or Amended filing) Fax: PLAINTIFF VS DEFENDANT Attorney for Plaintiff name: Address: Phone: Attorney for Defendant name: Address: Phone: 1. Date PIP ORDER signed by Judge. 2. 3. If requesting mediation for more than one case with the same case style (same attorneys) but different assignee, list assignee name after the case number(s) below. 2. Case No.: Division: Assignee: 3. Case No.: Division: Assignee: Preferred dates/times 1. 2. 3. Contact the Program to get available dates/times (clear with opposing counsel) prior to faxing the request. American LegalNet, Inc. www.FormsWorkFlow.com