Form 50 - Information For Scheduling Mediation Prior To Trial Setting
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1INFORMATION FOR SCHEDULING MEDIATION PRIOR TO TRIAL SETTING
Date: _______________
Case No: _________________
Div. No.: _______
TYPE OF CASE: DIVORCE ______ PATERNITY _____ MODIFICATION _____ TEMPORARY _______
OTHER (SPECIFY)___________________.
IS EITHER PARTY CERTIFIED AS INDIGENT? __________
PETITIONER: _____________________________
RESPONDENT:______________________________
(Please circle)
Mr.
Mrs.
Ms.
(Please circle)
Mr.
Mrs.
Ms.
YOUR ANNUAL GROSS INCOME; $__________
YOUR ANNUAL GROSS INCOME; $____________
Your Address or attorney’s if you have an attorney
Your Address or attorney’s if you have an attorney
ADDRESS:
_____________________________
ADDRESS: _________________________________
________________________________________
___________________________________________
DAYTIME TELEPHONE #____________________
DAYTIME TELEPHONE #______________________
FAX NUMBER_____________________________
FAX NUMBER_______________________________
EMAIL:___________________________________
EMAIL______________________________________
ATTORNEY: _____________________________
ATTORNEY: ________________________________
G.A.L. (IF ANY):___________________________
GAL TELEPHONE NO:_________________________
GAL ADDRESS:___________________________________________________________________________
Please check issues:
Parental responsibilities ____ ;
time-sharing
_____ ;
child support _____ ;
equitable distribution (assets/debts) ______;
possession of home _____;
attorney fees _______ ;
alimony/spousal support _____ ;
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?____
State or County of Origin ______ If Orange County case , what is the case number ________________
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
(with the other side conferenced in, if possible). You may also check the website for Available
Dates at – Dispute Resolution Services.
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).
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. Form 50 (9/12/08)
*This Form 50 may expire in 30 days at which time it may be discarded. After that you may need to refile.
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