IN THE _________ _ COURT OF _____________ COUNTY, TENNESSEE ______________________________________________________________________________ ) Plaintiff/Petitioner ) ) vs. ) Docket No. _________________ ) ) Defendant/Respondent ) ______________________________________________________________________________ MOTION FOR REDUCED FEE MEDIATION______________________________________________________________________________ [ ] Plaintiff/Petitioner or [ ] Defendant/Respondent, ___________________________,moves this Honorable Court for leave to pay a reduced fee for mediation ordered by this Courton the _____ day of __________, 20____. As grounds for this Motion, the moving party herebystates as follows: 1. [ ] The address of the moving party is confidential or [ ] moving party residesat ________________________________________________________________________________________________________________________________________________________. 2. Moving party is [ ] unemployed, [ ] employment of moving party isconfidential, or [ ] moving party is employed at ___________________________________________________________________________________________________________________. 3. Moving party has a gross income of $_______________ per month, not includingany child support payments, as is shown by the following documentation: __________________________________________________________________________________, a copy of whichis attached hereto. 4. Moving party is responsible for the economic upkeep of __________ childrenwho live at home with the moving party. The only help the moving party receives in this regardis $_______________ per month from ______________________________________________. 5. The moving party has a combined gross income and child support income of$_____________ per month. 6. An affidavit is attached hereto which attests to the truth of the facts. WHEREFORE, MOVING PARTY PRAYS >>>> 2 That upon consideration by this Honorable Court, the moving party pay a reduced fee for mediation at the rate of $_________ per hour for in session and $_________ per hour for out of session work by the mediator in accordance with Divorcing Parent Education and Mediation Fund guidelines established by the Administrative Office of the Courts, a copy of which is attached hereto. Respectfully submitted, ___________________________________________ Printed Name ___________________________________________ Signature Date