FORM 50 - OSCEOLA COUNTY INFORMATION FOR SCHEDULING MEDIATION PRIOR TO SETTING TRIAL (This form will expire in 30 days at which time it will be discarded. After that date you will need to refile.) Date: _______________ TYPE OF CASE: Divorce_____ Case No: ______________ Paternity _____ Modification _____ Div. No.: ________ Temporary ______ Other (specify)______________________ Is either party certified as indigent? ______ If so, who?_________ Have the parties coordinated a date and time for the mediation conference? If so, please complete the following: Date of Mediation: ________________ Time: ___________ Mediator(if applicable):_____________________ PETITIONER: _____________________________ (Please circle) Mr. Mrs. Ms. RESPONDENT:_____________________________ (Please circle) Mr. Mrs. Ms. YOUR ANNUAL GROSS INCOME: $____________ YOUR ANNUAL GROSS INCOME: $____________ Important Message to Self-Represented (Pro se) Litigants: If you fear that disclosing your address would put you in danger, write "Confidential" on the address section of this form. You must complete a Request for Confidential Filing of Address Form, Florida Supreme Court Approved Family Law Form 12.980(h), and file it with the Office of the Clerk of the Circuit Court in Osceola County. ADDRESS: (Attorney's Address if you have an Attorney) ________________________________________ ________________________________________ DAYTIME TELEPHONE #____________________ FAX NUMBER_____________________________ E-MAIL:__________________________________ ATTORNEY: _____________________________ G.A.L. (IF ANY):___________________________ ADDRESS: (Attorney's Address if you have an Attorney) __________________________________________ _________________________________________ DAYTIME TELEPHONE #______________________ FAX NUMBER_______________________________ E-MAIL:____________________________________ ATTORNEY: ________________________________ GAL TELEPHONE NO:_______________________ GAL ADDRESS:___________________________________________________________________________ Please check the issues included in the Petition which are appropriate for mediation: Parental responsibility _____; Time-sharing _____; Child support ____; Exclusive possession of home_____; Equitable distribution(assets/debts) _____; Attorney fees ____; Alimony/spousal support _____; Other matters: _______________________________________. Has either party ever received public assistance? ___ Receiving it now?_____ Type:____________ Have you ever been involved with any other family case (DIFFERENT CASE #) with this party? _______ If so, what is the case number? __________________ State or County of Origin: ________________ The mediation must be conducted within 30-45 days unless extended by both parties. In order to obtain a date and time for a mediation conference, you may call the mediation office at (407)7422451 (preferably with the other side conferenced in, if possible) or you may complete the Form 50 and e-mail it to osceolamediation@ocnjcc.org or you may fax the Form 50 to (407) 835 - 5261. ACKNOWLEDGEMENT: By signing this form I am declaring that to the best of my knowledge there is no violence, threat of violence or substance abuse which would impede the mediation process. I further understand that the Mediation Fee is determined by the combined annual gross income of the parties (before deductions). PERSON SUBMITTING FORM 50:__________________________ PRINT NAME Copies to: ____ Respondent (or Attorney) Form 50-Osceola (Revised 05-2014) ____________________________ SIGNATURE ____ Petitioner (or Attorney) ____ Domestic Clerk _____ GAL American LegalNet, Inc. www.FormsWorkFlow.com