VOLUNTARY MEDIATION PROGRAM LAKE COUNTY DOMESTIC RELATIONS COURT MEDIATION REQUEST __________________________________ _______________________________________ NAME (Mother) NAME (Father) __________________________________ _______________________________________ ADDRESS ADDRESS __________________________________ _______________________________________ TELEPHONE NUMBER(S) TELEPHONE NUMBER(S) 1. I am the ________ Petitioner _______ Plaintiff ______ Defendant in Case Number ____________________. 2. I am represented by Attorney ___________________. 3. I am requesting mediation of issues involving: _______ Parenting time _______ Custody _______ Other Parental Rights and Responsibilities Issues; Designate: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. The current order in effect is: _______ Sole Residential Parenting _______ Shared Parenting Plan _______ Other; Designate _________________________ _______ Standard Order of Parenting Time for Non-Residential Parent _______ Primary Residence is with: ____ Mother ____ Father 5. Name(s) and age(s) of the child(ren):_________________________________ ____________ ________________________________________________________________________ ___ American LegalNet, Inc. www.USCourtForms.com>>>> 26. The other party is/is not willing and available to participate in mediation. 7. The other partys Attorney is ____________________. 8. There are/are no civil protection orders (TPO or CPO) or domestic violence charges between the parties (circle one). By submitting this form, I am requesting voluntary mediation services through the Lake County Domestic Relations Court Mediation Department. I understand that my former spouse will be contacted by the Courts Mediator as to this request. If my former spouse does not consent to voluntary mediation, this request cannot proceed. _____________________________________ Signature Date: ___________________ 03/2005 American LegalNet, Inc. www.USCourtForms.com