IN THE THIRTEENTH JUDICIAL CIRCUIT COURT OF MISSOURI FAMILY COURT DIVISION In re the Matter of __________________________ Petitioner and __________________________ Respondent FORM 15 Form 15 must be completed by Petitioner and filed no later than 60 days from the date of service, when a dissolution or motion to modify involves children. Check all that apply: 1. ____ The parties have completed two hours of Rule 68.12 mediation as verified by the Notice of Mandatory Mediation Compliance. 2. ____ The parties have no disputes regarding parenting issues regarding the children. 3. ____ The required mediation under Rule 68.12 has been waived by order of the Court. IF YOU HAVE SELECTED 1, 2, OR 3 ABOVE, YOU NEED ONLY SIGN THE AFFIDAVIT BELOW AND FILE FORM 15. IF YOU CANNOT SELECT 1, 2 OR 3 ABOVE, PLEASE CONTINUE. 4. ____ The parties have a dispute regarding parenting issues and have not been to a mediator: a._____ Parties request court appointed mediator b._____ Parties request ________________________________be appointed mediator Mediator's Address ________________________________ Mediator's Telephone ______________________________ c._____ Parties request MARCH mediation services (paternity cases, family access motions, and post-dissolution motions qualify for MARCH mediation services) 5. ____ There has been or there is a current Restraining Order or Protection From Abuse Order involving the parties or the child. The Petitioner's mailing address is: The Respondent's mailing address is: ___________________________________ _________________________________ ___________________________________ _________________________________ ___________________________________ _________________________________ Attorney for the Petitioner is: Attorney for the Respondent is: Name_______________________________ Name______________________________ Address_____________________________ Address____________________________ Phone______________Fax______________ Phone_________________Fax__________ AFFIDAVIT I hereby certify that the above Response to Rule 68.12 Mediation of Child Custody and Visitation Disputes is complete, true and accurate to the best of my knowledge and belief. _______________________________________________________ Affiant- Petitioner/Respondent Certificate of mailing: I hereby certify that a copy of the above and foregoing was mailed on this _____day of _______________, 20__, Signature:__________________________________________________________________________ Case No.: [Effective July 1, 2003] American LegalNet, Inc. www.FormsWorkFlow.com