File No. STATE OF NORTH CAROLINA County In The General Court Of Justice District Court Division Name And Address Of Plaintiff(s) MOTION AND ORDER TO WAIVE VERSUS CUSTODY MEDIATION Name And Address Of Defendant(s) G.S. 50-13.1(c) MOTION The undersigned party moves that mediation of this custody/visitation case through the mandatory custody mediation program be waived, and in support of the motion states: (Check only the boxes that apply) 1. The party making this Motion lives more than fifty (50) miles from the Court. 2. Custody mediation would be an undue hardship because . 3. The parties have agreed to private mediation subject to the approval of the Court. 4. The other party has abused or neglected the minor child(ren) involved in the case. 5. The other party suffers from alcoholism. abuses drugs. abuses me. 6. The other party has severe psychological, psychiatric, or emotional problems. I UNDERSTAND THAT I WILL HAVE TO APPEAR IN COURT AND OFFER EVIDENCE TO SUPPORT THE STATEMENTS I HAVE CHECKED ABOVE. Date Signature Of Movant Plaintiff Defendant NOTICE OF HEARING NOTICE TO THE DEFENDANT(S)/PLAINTIFF(S): You are hereby notified that this Motion To Waive Custody Mediation will be heard on the date, time and at the location set out below. You must be present if you wish to be heard. Date Of Hearing Time Of Hearing AM Location Of Hearing PM Date Signature Of Movant CERTIFICATE OF SERVICE I certify that on the date of mailing shown below a copy of this Motion and Notice was served on the opposing party(ies) at the address listed above by depositing a copy in a post-paid, properly addressed envelope in a post office or official depository under the exclusive care and custody of the United States Postal Service. Date Of Mailing Date Of Certification Signature Of Movant NOTE TO MOVING PARTY: Obtain from the Clerk a date, time and location for a hearing on this Motion. Fill in that information in the Notice of Hearing. Date and sign the Notice of Hearing and mail a copy to the other party by regular mail. Complete the Certificate of Service and file the original with the Clerk. AOC-CV-632, New 4/99 1999 Administrative Office of the Courts (Over) >>>> 2 ORDER 1. The Court concludes that the movant has shown good cause to waive mediation under the mandatory custody mediation program, and the motion is allowed. 2. Mandatory custody mediation is waived because the case is being referred to private mediation. If private mediation is unsuccessful, then the case is to be returned to Court for referral to the mandatory custody mediation program. 3. The motion is denied and it is ordered that this case be referred to the custody mediation program for mediation of all unresolved custody and visitation issues in the case. Date Name Of District Court Judge (Type Or Print) Signature Of District Court Judge AOC-CV-632, Side Two, New 4/99 1999 Administrative Office of the Courts