Form 4a-205 - Motion For Referral To Mediation (Child Support Or Other Financial Issues) (Domestic Relations Actions) Page 2

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[ ]
I CANNOT TALK TO THE OTHER PARTY because there is a protective
order between the other party and me, and the other party does not have an
attorney.
[ ]
I HAVE NOT TALKED TO THE OTHER PARTY because:
____________________________________________________________
____________________________________________________________
___________________________________________.
__________________________________
Signature
__________________________________
Name (printed)
__________________________________
Address
__________________________________
Telephone number
CERTIFICATE OF SERVICE
I certify that on ____________ (date), I (check the applicable item below and fill in all
information)
[ ]
mailed a copy of this motion by United States mail, postage prepaid, to:
Name:
__________________________________
Mailing address:
__________________________________
City, state and zip code:
__________________________________;
[ ]
delivered a copy of this motion to ________________________ (the other party or the other
party’s attorney); or
[ ]
faxed a copy of this motion to _____________________ (the other party or the other party’s
attorney) using the following fax number: ___________________. The transmission was
reported as complete and without error. The time and date of the transmission was _____
(a.m) (p.m) on _______________ (date).
________________________________
Signature of attorney
________________________________
Date of signature

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