IN THE THIRTEENTH JUDICIAL CIRCUIT COURT OF MISSOURI
FAMILY COURT DIVISION
| In re the Matter of |   | 
| __________________________ |   | 
| Petitioner |   | 
| and | Case No.: | 
| __________________________ |   | 
| Respondent |   | 
|   | FORM 15 | 
Form 15 must be completed by Petitioner and filed no later than 60 days from the date of service, when a dissolution or motion to modify involves children.
Check all that apply:
1.____ The parties have completed two hours of Rule 68.12 mediation as verified by the Notice of Mandatory Mediation Compliance.
2.____ The parties have no disputes regarding parenting issues regarding the children.
3.____ The required mediation under Rule 68.12 has been waived by order of the Court.
IF YOU HAVE SELECTED 1, 2, OR 3 ABOVE, YOU NEED ONLY SIGN THE AFFIDAVIT BELOW AND FILE FORM 15. IF YOU CANNOT SELECT 1, 2 OR 3
ABOVE, PLEASE CONTINUE.
4.____ The parties have a dispute regarding parenting issues and have not been to a mediator:
| a._____ | Parties request court appointed mediator | 
| b._____ | Parties request ________________________________be appointed mediator | 
|   | Mediator’s Address ________________________________ | 
|   | Mediator’s Telephone ______________________________ | 
| c._____ | Parties request MARCH mediation services (paternity cases, family access motions, and | 
|   | post-dissolution motions qualify for MARCH mediation services) | 
5.____ There has been or there is a current Restraining Order or Protection From Abuse Order involving the parties or the child.
| The Petitioner’s mailing address is: | The Respondent’s mailing address is: | 
| ___________________________________ | _________________________________ | 
| ___________________________________ | _________________________________ | 
| ___________________________________ | _________________________________ | 
| Attorney for the Petitioner is: | Attorney for the Respondent is: | 
| Name_______________________________ | Name______________________________ | 
| Address_____________________________ | Address____________________________ | 
| Phone______________Fax______________ | Phone_________________Fax__________ | 
AFFIDAVIT
I hereby certify that the above Response to Rule 68.12 Mediation of Child Custody and Visitation Disputes is complete, true and accurate to the best of my knowledge and belief.
_______________________________________________________
Affiant- Petitioner/Respondent
Certificate of mailing: I hereby certify that a copy of the above and foregoing was mailed on this _____day of
_______________, 20__,
Signature:__________________________________________________________________________
 
 
IN THE THIRTEENTH JUDICIAL CIRCUIT COURT OF MISSOURI
FAMILY COURT DIVISION
In the Matter of
______________________________
Petitioner
and
Case No: ____________________
______________________________
Respondent
NOTICE OF MANDATORY MEDIATION COMPLIANCE
Please check all that apply:
The parties complied with the court order to mediate.
|  An agreement |   | was |   | was not reached |   | parties continue in mediation. | 
The Petitioner did not comply with the court order to mediate.
The Respondent did not comply with the court order to mediate.
The mediator requests leave to withdraw due to a conflict of interest.
The differences of the parties were resolved prior to mediation.
Not appropriate under M.A.R.C.H. Guidelines based on director’s review.
Other: ______________________________________________________
| ________________________ | _________________________ | 
| Mediator (print name) | Date | 
| _________________________ |   | 
| Mediator’s signature |   | 
|   | [Effective July 1, 2003] |