STATE OF NORTH CAROLINA COUNTY OF _____________________ GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO.: _________________________ REQUEST FOR EXEMPTION FROM MANDATORY CHILD CUSTODY MEDIATION _________________________ Plaintiff VS. _________________________ Defendant I request an exemption from Mandatory Child Custody Mediation for the following reason: do not reside in this county and the driving time requires more than one hour; and it is my I opinion that this inconvenience outweighs the benefit of participating in child custody mediation. am a victim of domestic violence, and I am concerned about the appropriateness of I participating in mediation. I have discussed this problem with the Custody Mediator and after doing so, I request that I be excused from participating in child custody mediation. have recently participated in Child Custody Mediation and it was not successful and it is We my opinion that no useful purpose will be served by further participation. Other: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ____________________________________________________________ This ___ day of ____________, 20 __. _________________________________ Printed name _________________________________ Signed name Determination The request for exemption is approved denied. This ___ day of ____________, 20 __. _________________________________ District Court Judge FC Rev. 7/11/2010 American LegalNet, Inc. www.FormsWorkFlow.com