ADMINISTRATIVE OFFICE OF THE NINETEENTH JUDICIAL Lake County Courthouse 18 North County Street Waukegan, lL 60085-4359 Lake County Arbitration Center 415 W Washington Street, Suite 106 Waukegan, IL 60085-4359 CI R C U I T Lake County, Illinois TDD: 847.360.2975 Fax: 847.984.5613 Phone: 847.377.3600 TDD: 847.360.2975 Fax: 847.263.7758 Phone: 847.377.3700 Instructions for Certification as a Court Approved Mediator These instructions and the attached Petition for Certification As Court Approved Mediator form are for use in connection with: The Lake County Family Mediation Program pursuant to Local Rule 11.13 The Lake County Civil Mediation Program pursuant to Local Rule 20.00 The Lake County Probate Mediation Program pursuant to Local Rule 14.28 Individuals interested in being approved to serve as a mediator should send a completed Petition for Certification As Court Approved Mediator form and all attachments required by the petition to: Lake County Arbitration Center 415 W. Washington Street, Suite 106 Waukegan, IL 60085 For questions, please call the Arbitration Center at 847-377-3700. The petition will be forwarded to the appropriate judge for consideration and you will be notified whether your Petition has been granted or denied. Please refer to the Local Rules of the 19th Judicial Circuit for the most current qualification requirements. American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS IN THE MATTER OF THE CERTIFICATION OF (name of applicant) PETITION FOR CERTIFICATION AS COURT APPROVED MEDIATOR , (name of applicant) and petitions The Honorable Presiding Judge for certification as a court approved Mediator and in support thereof states as follows: 1. I am petitioning for certification for: The Lake County Family Mediation Program pursuant to Local Rule 11.13 The Lake County Civil Mediation Program pursuant to Local Rule 20.00 The Lake County Probate Mediation Program pursuant to Local Rule 14.28 2. I have satisfactorily completed a 40-hour mediation program, proof of which is attached as Exhibit A. (For the Family Mediation Program the program must be divorce specific.) 3. I have have not completed training specific to domestic violence, child abuse, substance abuse and mental illness, proof of which is attached as Exhibit B. I understand that the presence of domestic violence, child abuse, substance abuse and/or mental illness may impair the abilities of the parties to negotiate effectively. (not required for Civil Mediators) 4. a) I have a degree in law, (required for Civil and Probate Mediators) or b) I have a graduate degree in Psychiatry Social Work Family Counseling Other field of behavioral science substantially related to marriage and family counseling. Specify: ___________________________________________________ Other field of study: __________________________________________ 5. I have a valid license from the State of Illinois to practice my profession, proof of which is attached as Exhibit C. 6. I am a member in good standing in the following professional organization(s). ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Now comes Psychology Human Development 12/11 7. If you have been engaged in the practice of law, indicate the approximate percentage of time devoted to the following types of practice. ("Litigation" includes, in addition to actual time in court or tribunal, preparation therefore. "Court" indicates federal and state judicial system; "Trib" indicates quasi-judicial tribunals, e.g. Industrial Commission, NLRB hearings, etc.; "Non-Lit" indicates practice not involving litigation.) Type of Practice Litigation Court % Litigation Other Trib. % Non-Lit % Anti-Trust & Trade Regulation Bankruptcy Chancery Corporate and Securities Criminal (Felony) Criminal (Misd./Traffic) Environmental Family Law Labor Relations Patent Probate & Estate Planning Real Estate State & Local Government Tax (Federal) Tax (State, Local) Tort (Personal Injury) Tort (P.D., Subrogation) Worker's Compensation Other: Other: 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 8. A) Jury Trial Experience (Please state your jury trial experience in actual or approximate numbers.) Jury Cases Started But Which Did Not Jury Cases to Verdict go to Verdict Civil Criminal Civil Criminal As Lead Trial Counsel As Counsel Assisting at Trial B) List the last two jury cases tried to verdict, during the past five years, including names of other attorneys and Judge. Case One Case Two Name of Case County Judge Attorney(s) 9. Non-Jury Trial Experience (Please state in actual or approximate numbers.) Civil Number of contested Non-Jury cases commenced How many of these cases went to judgment after the trial on the merits? Page 2 of 3 12/11 American LegalNet, Inc. www.FormsWorkFlow.com Criminal 10. I carry professional liability insurance covering the mediation process, proof of which is attached as Exhibit D. 11. Family Mediators a) I have a minimum of two years of work experience in my discipline or profession, or b) I do not have a minimum of two years of experience in my discipline or profession but I will be supervised by ____________________________________ a mediator on the court's list of approved Mediators. and c) I understand that I must attend ten (10) hours of continuing education every two (2) years, on subjects related to child custody, visitation, domestic violence, substance abuse, mental illness or other areas relevant to family law practice. Civil Mediators d) I have a minimum of eight years of litigation experience. Probate Mediators e) I have a minimum of ____ years probate experience or in my indicated type of practice. and f) I understand that I must attend ten (10) hours of continuing education every two (2) years, on subjects related to probate, trusts, guardianship, taxation or other areas relevant to probate practice. 12. I maintain an office in the County of ________________ at the followi