REV 2/2019 JDB REQUEST FOR MEDIATION 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Code: 2095 Name: Address: Telephone: Email: Self-Represented Litigant IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE , Plaintiff / Petitioner / Joint Petitioner, Case No. Dept. No. vs. , Defendant / Respondent / Joint Petitioner. / REQUEST FOR MEDIATION A.Child 1: Child 2: Child 3: If more room is needed, attach additional sheets. Minor Child(ren) Print the name(s) of the minor child(ren) below. (First and Last Name) (First and Last Name) (First and Last Name) (Date of Birth) (Date of Birth) (Date of Birth) American LegalNet, Inc. www.FormsWorkFlow.com REV 2/2019 JDB REQUEST FOR MEDIATION 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 B. I request that mediation be ordered for the purpose of the parents attempting to work together to resolve the following issue(s): Custody / Visitation Holiday Schedule Vacation Schedule School Enrollment Relocation Extra-Curricular Activities Other: C. If more room is needed, attach additional sheets. Reason(s) for Mediation Check all of the boxes that apply. Reason(s) for Mediation, Continued In detail, tell the Court why you believe your request for mediation should be granted. American LegalNet, Inc. www.FormsWorkFlow.com REV 2/2019 JDB REQUEST FOR MEDIATION 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 D. Yes No I have completed an updated financial declaration that I will file with this Request for Mediation. Yes No I understand that there is a fee to use the Court mediation program. (Fees range from $0 to $300.00, per person, based upon income). Yes No The Court previously ordered that we are to attend mediation prior to filing a Motion. If yes, date of the Order / Decree: . Yes No I request to appear at mediation by telephone, because of the following circumstances: . This document does not contain the personal information of any person as defined by NRS 603A.040. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. Date: Your Signature: Print Your Name: Additional Information Select 223Yes224 OR 223NO224 by checking one box next to each statement. American LegalNet, Inc. www.FormsWorkFlow.com