Request For Confidential Mediation Regarding Visitation Page 2
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4PR-E-LP-025
4. A controversy exists between the below parties concerning visitation. (List parties name and relationship
then provide a brief explanation):
,
(name)
(relationship)
,
(name)
(relationship)
,
(name)
(relationship)
,
(name)
(relationship)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Provide the following information regarding any other custody proceeding pending in the California court or
any other court concerning the child to this proceeding:
Name of the court, state, location, and case number:
6. Date of last Mediation Report. (If applicable): ________________
7. Do you have a current Domestic Violence Restraining Order?
Yes (If yes, attach a copy)
No
8. Any information I have provided above and any attachment to this Petition are furnished in good faith in the
hope of settling the controversy.
I declare under penalty of perjury under the laws of the State of California that the foregoing information is true
and correct.
Dated: _____________
________________________________________
PRINT NAME
SIGNATURE OF PETITIONER
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Page
PR-E-LP-025 (Revised 1/11/16)
Request for Confidential Mediation Regarding Visitation
Local Rule 4.33
Mandatory
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