Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4134V, 05/17 Request for Court Ordered Mediation 247247767.405 and 807.05, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 Enter the name of the county in which this case is filed. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Check marriage or paternity. If paternity, enter initials of child. IN RE: THE MARRIAGE PATERNITY OF Petitioner/Joint Petitioner A Name (First, Middle and Last) and Enter the name of the Petitioner/Joint P etitioner A. Request for Court Ordered Mediation Case No. Enter the name of the Respondent/Joint P etitioner B. Respondent/Joint Petitioner B Name (First, Middle and Last) Enter the case number. Party requesting mediation : Enter your name, address, and phone numbers. Name Address Address City State Zip Phone [Day] [Evening] Relationship to child(ren) Parent Other person with court ordered placement: Describe the problems you are experiencing with the current physical pl acement or legal custody order. Add additional pages if necessary. I request court ordered mediation to help resolve the following problems with legal custody and/or physical placement : Other Party(ies) : Enter the other party(ies) name, address, and phone numbers. Name Address Address City State Zip Phone [Day] [Evening] For additional parties, see attached. I understand that mediation is not a court hearing . I understand that I may need to file a motion before further court proceedings will be scheduled if we are not able to settle our disagreements in mediation . I understand I must send a copy of this request to the other party(ies) . Sign and print your name. Enter the date on which you signed your name. Note: This signature does not need to be notarized. Signature Print or Type Name Date American LegalNet, Inc. www.FormsWorkFlow.com