Office of Dispute Resolution SEVENTH JUDICIAL ADMINISTRATIVE DISTRICT P.O. BOX 963 CARTERSVILLE, GA 30120 www.7jad.com PHONE: (770) 387-4820 TOLL FREE: (877) 655-6865 FAX: (770) 387-5479 Civil and Domestic Mediation Scheduling Form STEP ONE Civil Action #: Style of Case: Name of Mediator: Date of Mediation: STEP TWO PLAINTIFF'S DATA Name: (Last, First MI) Mail Address City, State and Zip Phone Attorney's Name City, State and Zip Phone Email / Fax County: vs Location of Mediation: Time of Mediation: DEFENDANT'S DATA Name: (Last, First MI) Mail Address City, State and Zip Phone Attorney's Name City, State and Zip Phone Email / Fax _____________________________________ STEP THREE _____________________________________ No unilateral scheduling is permitted. By signing below, I am stating that the choice of mediator, date, time, and location listed above is the result of a mutual decision made between Plainiff(s). Defendant(s), and Mediator. Print Name: (Last, First MI) Attorney Office Signature Required / Date Phone Please give a brief description of any special circumstances. It is essential that copies of all documents bearing on issues to be resolved be brought to the mediation session (financial, medical, business, etc.) STEP FOUR Domestic Relations Only (please circle appropriate response) Divorce: Modification: Alimony / Child support / Custody / Debt Division / Property Division Alimony / Child Support / Custody / Visitation Are there concerns of abuse (spouse, child, substance, etc) that are alleged or otherwise indicated? Y / N American LegalNet, Inc. www.FormsWorkFlow.com