OFFICE OF DISPUTE RESOLUTION THIRD JUDICIAL ADMINISTRATIVE DISTRICT 706-653-4190 706-653-4462 Fax CIVIL AND DOMESTIC ADR REFERRAL FORM Civil Action #: ________________ Judge: ______________Court: ____________________ Date Action Filed: _____________ County: _____________Neutral Selected: ___________ PLAINTIFF: It is the plaintiff's responsibility to fill out the entire form. PLAINTIFF'S DATA Name: ___________________________________ Mail Address: ______________________________ City, State, ZIP: ____________________________ Home Phone: ______________________________ Business Phone: ____________________________ Attorney's Name: ___________________________ Street Address: _____________________________ Mail Address: _______________________________ City, State, ZIP: _____________________________ Business Phone: ____________________________ Fax: ______________________________________ DEFENDANT'S DATA Name: ___________________________________ Mail Address: ______________________________ City, State, ZIP: ____________________________ Home Phone: ______________________________ Business Phone: ____________________________ Attorney's Name: ___________________________ Street Address: _____________________________ Mail Address: _______________________________ City, State, ZIP: _____________________________ Business Phone : ____________________________ Fax: ______________________________________ Please attach additional sheets for multi-party cases. Please give a brief description of case/claim or any special circumstances. ________________________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ CIVIL CASES ONLY Is an Insurer involved in this case? ____ Yes ____ No Please list name and address _________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ It is essential that copies of all documents bearing on the issues to be resolved be brought to the session (i.e. financial, medical, business, insurance, etc.) Will attorneys attend the session? ____ Yes ____ No DOMESTIC RELATIONS ONLY ____ Divorce: ___ Alimony ___Child Support ___Custody ___Debt Division ___ Property Division _____ Modification: ___Alimony ___Child support ___Custody ___Visitation IF THERE ARE CONCERNS ABOUT ANY TYPE OF DOMESTIC VIOLENCE/ABUSE (SPOUSE, CHILD, SUBSTANCE, ETC.) WHICH IS ALLEGED OR OTHERWISE INDICATED, PLEASE CHECK HERE: _______ YES (BLANK RESPONSE INDICATES NO ALLEGATIONS). If children's issues are to be mediated, both parties are required to attend the Divorcing Parents Seminar. THIS FORM MUST BE FILLED OUT COMPLETELY Office of Dispute Resolution TH 308 10 STREET COLUMBUS, GA 31901 American LegalNet, Inc. www.FormsWorkFlow.com