Fill and Sign the Ordered Mediation Form

PRINT in BLACK ink Enter the name of the county in which this case is filed. STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Check marriage or paternity. If paternity, enter initials of child. In re the Marriage Paternity of:       Petitioner/Joint Petitioner-Wife:       First name Middle name Last name andEnter the name of the petitioner. If joint petitioners, enter the name of the wife. Enter the name of the respondent. If joint petitioners, enter the name of the husband. Respondent/Joint Petitioner-Husband:       First name Middle name Last name Request for Court Ordered Mediation Case No.       Enter the case number. To: Circuit Court Commissioner Name       Address       Address       City       State       Zip       From: Name       Address       Address       City       State       Zip       Phone (day)       Phone (evening)       I Request Court Ordered Mediation with: Name       Address       Address       City       State       Zip       Phone (day)       Phone (evening)       The other parent and I have been unable to work out problems with legal custody and/or physical placement. The problem(s) we have are:       Add additional pages if necessary I understand that this is not a court hearing. If we are able to settle our disagreements in mediation, we may not need to go to court. I understand I must send a copy of this request to the other parent. FA-4134 Pro Se, 10/06 Request for Court Ordered Mediation §§767.405 and 807.05, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2Enter your name, address, and phone numbers. Enter the other parent’s name, address, and phone numbers. Describe the problems you are experiencing with the current physical placement or legal custody order. Add additional pages if necessary. Enter the name and address of the Family Court Commissioner of the county in which your case is filed. Sign and print your name. Enter the date on which you signed your name. Note: This signature does not need to be notarized. Signature       Print or Type Name       Date Error! Unknown document property name. 7, 1/16/05 Joint Error! Unknown document property name. No Children Error! Unknown document property name. Page 2 of 2