FORM Med-E NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE COUNTY DISTRICT COURT DIVISION File No. -CVD- ) Plaintiff ) ) MOTION FOR EXEMPTION ) FROM MEDIATION AND THE vs. ) PARENTING APART PROGRAM ) ) ) Defendant ) Pursuant to G.S. 50-13.1, the undersigned attorney/party request a waiver of court ordered custody/visitation mediation and the Parenting Apart Program based upon the following reason(s): 1. The parties have agreed to voluntary private mediation. 2. The party resides more than 50 miles from the court. 3. There are allegations of abuse or neglect of the minor child. 4. There are allegations of alcoholism, drug abuse, or domestic violence. 5. There are allegations of severe psychological, psychiatric or emotional problems. 6. Other good cause The facts upon which this request for waiver is based are so follows: This is the day of , 20. Date Signature of Filing Party Copy to: Custody Mediator Case Coordinator American LegalNet, Inc. www.FormsWorkFlow.com