INFORMATION FOR SCHEDULING MEDIATION PRIOR TO TRIAL SETTING

Date: _______________ Case No: _________________ Div. No.: _______

TYPE OF CASE: _____ DIVORCE _____ PATERNITY _____ MODIFICATION _____ TEMPORARY

____________OTHER (SPECIFY). CERTIFIED BY THE CLERK AS INDIGENT: __Petitioner __ Respondent

PETITIONER: _____________________________         RESPONDENT:_____________________________

(Please circle) Mr. Mrs. Ms.                                   (Please circle) Mr. Mrs. Ms.

PETITIONERS ANNUAL INCOME $___________ RESPONDENTS ANNUAL INCOME $____________

ATTORNEY: _____________________________          ATTORNEY: ________________________________

Address for attorney or if no attorney, your address:       Address for attorney or if no attorney, your address

ADDRESS: _____________________________         ADDRESS: _________________________________

________________________________________ ___________________________________________

DAYTIME TELEPHONE #____________________         DAYTIME TELEPHONE #______________________

FAX NUMBER_____________________________ FAX NUMBER_______________________________

EMAIL:___________________________________         EMAIL______________________________________

G.A.L. (IF ANY):___________________________          GAL TELEPHONE NO:_________________________

GAL ADDRESS:___________________________________________________________________________

Please check issues: ____ parental responsibility; ____ visitation; _____ child support; ____ alimony;

_____ exclusive possession of home; ____ equitable distribution (assets/debts) ______;attorney fees; _______

other______________________________________________________

Has either party ever received any public assistance___Receiving it now? ____ Type:___________

Have you ever been involved with any other family case (different case #) with this party?_______

If so, what is the case number __________________________ State or County of Origin _________

 The mediation must be conducted within 30 days unless extended by agreement of parties.

 You may call the mediation office at (407)836-2004 to obtain a date and time for mediation (preferably with the other side conferenced in, if possible). You may also check the website (left bottom of home page) for Available Dates at NINJA9.org

By signing this form I am declaring that to the best of my knowledge there is no significant violence or substance abuse which would impede the mediation process. (If you feel that you will not be able to make decisions without being intimidated by the other party, please call us at (407) 836-2004). Please FAX this Information Form to (407) 836-2367 or mail to 425 N. Orange Avenue Room 120, Orlando, FL 32801

_______________________________

SIGNATURE

cc: ___ Respondent (or Att’y) ____ Petitioner (or Att’y) cc: ___ Domestic Clerk                        Rev. (4/07)

*This Form may expire in 30 days at which time it may be discarded. After that you may need to refile.