STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT WINNEBAGO COUNTY IN RE THE MARRIAGE OF: PLAINTIFF VS CASE NO. DEFENDANT ORDER APPOINTING MEDIATOR This cause coming on by stipulation of the parties, plaintiff's or defendant's Petition for Mediation or the court's Motion for Mediation, the court being fully advised in the premises and having jurisdiction of the subject matter; IT IS THEREFORE ORDERED: [1] The parties are to participate in mediation pursuant to local court rules. [2] , , (Name) (Address) (Phone) [3] [4] [5] Each party is to individually call the mediator within two business days of this date to schedule the requirement appointments. This case is set for status on at . Plaintiff to be responsible for % of the mediation costs; defendant to be responsible for the remaining portion. Pursuant to financial affidavits presented to the court, this is a(n) [ ] reduced fee case [ ] indigency case. (If marked, please check the appropriate box). Counsel are to provide a copy of the order to the mediator. day of ENTER: , year [6] DATED this JUDGE Plaintiff (Name) (Address) (Phone) (Plaintiff's Attorney) Defendant: (Name) (Address) (Phone) (Defendant's Attorney) APPENDIX Y Amended: 01/02/07 American LegalNet, Inc. www.FormsWorkflow.com