COVER SHEET FOR CUSTODY MEDIATION IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION COUNTY OF CUMBERLAND FILE NO.: ________ -CVD- _____________ JUDICIAL DISTRICT 12 Assigned Judge: ___________________ Plaintiff________________ vs. Defendant________________ Day Phone: PLAINTIFF(S): Mailing Address: Date of Birth: Plaintiff's Attorney: Address: DEFENDANT(S): Mailing Address: Date of Birth: Defendant's Attorney: Address: Night Phone: Email: Phone: Fax: Email: Day Phone: Night Phone: Email: Phone: Fax: Email: 1. Is there a pending or resolved military, civil or criminal domestic violence case involving the same parties in North Carolina or any other state? YES NO List type: ________________ Expiration date: ___________ If yes, you must attach a copy of all military, civil or criminal domestic violence restraining/protective orders. 2. Is DSS/CPS currently involved? YES NO Prior involvement? YES NO Date closed: ____________ List date opened: ________________ and reason case opened: _________________________________________ DSS Social Worker's name ________________________ County: ________________Tel#:__________________ 3. Is an interpreter needed for a participant? YES NO If yes, what language(s) does the party speak? Spanish YES NO Other? ___________________________ 4. Have the parties attended orientation in the past 5 years? YES NO If yes, case/file number: ____-CVD-______ 5. Have the parties ever attended mediation? YES NO If yes, case/file number: _____-CVD-_______ Online/WebEx Orientation or Mediation Requested YES NO (must have private setting/email/internet) Reason for Request (check one or more): Out-of-state/over 3 hours' drive (list state/distance_________); DVPO ; Medical ; Other ? List reason: _______________________________________________________ CHILDREN INVOLVED IN CASE: (use back of form if needed): NAME AGE M/F DOB CHILD RESIDES WITH RELATIONSHIP STATE OF NORTH CAROLINA Marriage Date: ______________ Separation Date: _________ Parties Never Married: ___________ Signature: _______________________________________________ Date: ____________________ Plaintiff Plaintiff's Attorney Defendant Defendant's Attorney Intervenor Intervenor's Attorney CCLF-FC-015 (4/16) CUSTODY MEDIATION RECEIVED DATE: ______________________ American LegalNet, Inc. www.FormsWorkFlow.com