STATE OF SOUTH CAROLINA COUNTY OF ________________________ ____________________________________ Plaintiff, vs. ____________________________________ Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) IN THE FAMILY COURT ________ JUDICIAL CIRCUIT REQUEST FOR APPOINTMENT OF MEDIATOR __________-DR - ______- __________ Case File Date: ______________ Plaintiff/Attorney for Plaintiff: Office Address: Telephone: Email Address: SC Bar #: Defendant/Attorney for Defendant: Office Address: Telephone: Email Address: SC Bar #: Pursuant to Rule 4(d)(2)(C) of the South Carolina Alternative Dispute Resolution Rules (SCADR), I hereby request that the Clerk of Court appoint a primary mediator and a secondary mediator for this action utilizing the process prescribed for in Rule 4(d)(2)(B), SC ADR. Mediator requested by: Attorney for Plaintiff Pro se Litigant Attorney for Defendant ____________________________________ Attorney or Pro Se Litigant Signature Date: _________________ SCADR 109 (05/2015) American LegalNet, Inc. www.FormsWorkFlow.com