STATE OF NORTH CAROLINA Harnett County File Number In The General Court Of Justice District Court Division Name of Plaintiff(s) VERSUS Name of Defendant(s) ATTORNEY CHECKLIST Plaintiff Attorney (Print Name) Defendant Attorney (Print Name) PRE-MEDIATION Consent Order Voluntary Dismissal Waiver Date: __________________________________________ Plaintiff Attorney Defendant Attorney POST- MEDIATION Full Parenting Agreement or Consent Order Partial Parenting Agreement Parenting Agreement NOT signed Extend sign/return time until Date signed: Date signed: *Note: Attorney will calendar case for court Date: _____________________________________________ Plaintiff Attorney Defendant Attorney Dom-5 (rev. 10/2014) District 11 ­ Custody Mediation American LegalNet, Inc. www.FormsWorkFlow.com