Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Request For Court Ordered Mediation Form. This is a Wisconsin form and can be use in Circuit Court Statewide.
Loading PDF...
Tags: Request For Court Ordered Mediation, FA-4134, Wisconsin Statewide, Circuit Court
FORM SUMMARY
Name of Form:
Request for Court-Ordered Mediation
Form Number:
FA-4134
Statutory Reference:
§§767.405 and 807.05, Wisconsin Statutes
Benchbook Reference:
Purpose of Form:
A party who wants to have issues concerning a legal
custody or physical placement situation may use this form
to request an order from the court that would require the
parties to participate in mediation of those issues.
Who Completes It:
The party seeking the mediation.
Distribution of Form:
Original will be filed with the court.
served on the other parties.
Accompanying Forms:
Although none are specifically required, it may be best
practice to attach a copy of any existing court order that
covers the custody or placement issue.
New Form/Modification:
Modification; last update 01/06.
Modification:
Updated to be compliant with 2005 Wisconsin Act 443.
Effective 01/07.
Comments:
A specific form ordering the mediation has not been
prepared because each court usually has its own order.
About this Form:
This form is the product of the Wisconsin Records
Management Committee, a committee of the Director of
State Court’s Office. As a pro se form, its use is NOT
mandatory but it is required to be accepted and
distributed by the circuit courts of the State of
Wisconsin.
A copy would be
Date: 10/05/2006
American LegalNet, Inc.
www.FormsWorkflow.com
PRINT in BLACK ink
Enter the name of the
county in which this case
is filed.
Check marriage or
paternity. If paternity,
enter initials of child.
Enter the name of the
petitioner. If joint
petitioners, enter the name
of the wife.
Enter the name of the
respondent. If joint
petitioners, enter the name
of the husband.
For Official Use
STATE OF WISCONSIN, CIRCUIT COURT,
COUNTY
In re the
Marriage
Paternity of:
Petitioner/Joint Petitioner-Wife:
First name
Middle name
Last name
and
Respondent/Joint Petitioner-Husband:
Request for Court Ordered
Mediation
First name
Middle name
Last name
Case No.
Enter the case number.
Enter the name and
address of the Family
Court Commissioner of
the county in which your
case is filed.
To: Circuit Court Commissioner
Name
Address
Address
State
Zip
City
State
Zip
Phone (day)
Phone (evening)
City
Enter your name,
address, and phone
numbers.
Enter the other parent’s
name, address, and phone
numbers.
From:
Name
Address
Address
I Request Court Ordered Mediation with:
Name
Address
Address
Zip
City
Describe the problems
you are experiencing
with the current physical
placement or legal
custody order. Add
additional pages if
necessary.
State
Phone (day)
Phone (evening)
The other parent and I have been unable to work out problems with legal custody and/or physical
placement. The problem(s) we have are:
Add additional pages if necessary
I understand that this is not a court hearing. If we are able to settle our disagreements in
mediation, we may not need to go to court. I understand I must send a copy of this request to
the other parent.
Sign and print your name.
Signature
Enter the date on which
you signed your name.
Note: This signature does
not need to be notarized.
Print or Type Name
Date
FA-4134 Pro Se, 10/06 Request for Court Ordered Mediation
§§767.405 and 807.05, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
American LegalNet, Inc.
Page 1 of 1
www.FormsWorkflow.com
