IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF DESCHUTES PROBATE DEPARTMENT In the matter of: ) ) Case No: ) ) REQUEST FOR MEDIATION ) ) ) I, , am the (petitioner), (proposed protected person), (other interested party) in this matter. I am requesting that the court refer this matter to mediation. I will provide a copy of this request to the other interested parties. Signed: Date: (Relationship to case) I certify that I (gave) or (mailed) a copy of this Request to the other parties listed below: Person served: Date served: Signed: Date: American LegalNet, Inc. www.FormsWorkFlow.com