IN THE THIRTEENTH JUDICIAL CIRCUIT COURT OF MISSOURI
FAMILY COURT DIVISION
In re the Matter of |
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__________________________ |
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Petitioner |
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and |
Case No.: |
__________________________ |
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Respondent |
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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 |
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Mediator’s Address ________________________________ |
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Mediator’s Telephone ______________________________ |
c._____ |
Parties request MARCH mediation services (paternity cases, family access motions, and |
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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: |
___________________________________ |
_________________________________ |
___________________________________ |
_________________________________ |
___________________________________ |
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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 |
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was |
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was not reached |
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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: ______________________________________________________
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_________________________ |
Mediator (print name) |
Date |
_________________________ |
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Mediator’s signature |
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[Effective July 1, 2003] |