IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA DOM ESTIC RELATION S DIVISION _________ CASE NUM BER _________________________ _______________________________________, Petitioner/P laintiff, and ________________________________________, Resp ondent/Defendant. COVER SHEET-CASE AT ISSUE (TO BE FILED AFTER M EDIATION AND W ITH NOTICE FOR TRIAL) Please set this case for trial for the following reason(s): This case has been to a full mediation (not mediation of temporary matters) of all issues on ___________________________________. The Certified Mediator who conducted the mediation was _______________, and an impasse was declared on ( ) all issues, or on ( ) some issues. _______ A Default was entered on __________________________________. _______ The Court has found that there has been a history of domestic violence that would impede the mediation process. _______ A mediation was scheduled but the (_____) Petitioner or (_______) Respondent failed to appear, and the other party has chosen not to reschedule another session. _______ A party is unavailable for mediation either in person or by telephone because he/she: ________ is not subject to the jurisdiction of this court and has refused to participate, ________ currently resides in another country; or, ________ is imprisoned out of state. ________ A Motion to Dispense With Mediation was granted by court order dated __________________ because the Court determined that: _________ Mediation of the issues would not be appropriate under the circumstances of the case. _________ Due to exigent circumstances a hearing before the Court should be expedited. _________ Other reasons: _______________________________________ _______________________________________. ______ __________________________________________ Signature Date___________________ __________________________________________ Print Name and Title 2002 © American LegalNet, Inc. Form 51 (10/01)