Fill and Sign the Visitation Mediation Program Form

Page 1 of 2 Civ. R. 100 DR-405 (10/07)(st.3) AS 25.20.080 MOTION FOR MEDIATION AS 25.24.060 & .140 IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) CASE NO. ) ) MOTION FOR MEDIATION THROUGH ) CHILD CUSTODY & ) VISITATION MEDIATION PROGRAM This motion is filed by (check one) Mother Father Both parties I ask the court to order the parties to parti cipate in mediation through the Child Custody and Visitation Mediation Program . In support of this request, I state as follows: 1. The parties have at least one minor child and cannot agree on custody or visitation. 2. I understand that Alaska law restricts the court’s ability to order mediation if domestic violence has occurred betw een the parties. I certify that: a. There is no domestic violence prot ective order currently in effect (no Alaska court order and no order iss ued in another state and filed in Alaska). b. In addition, one of the following is true (check one): No domestic violence has occurred between the parties. Domestic violence has occurred between the parties, but mediation should still be permitted because it is requested by the victim and the victim is signing this motion. 3. I understand that the parties’ combined net annual income must be less than $100,000 in order to partic ipate in the program. Mother’s net annual income: $ Father’s net annual income: $ (The above amounts should be the same as the “NET INCOME” amounts in the parties’ Child Support Guidelines Affidavit s. Estimate the other party’s net annual income if that party has not fil ed an affidavit and the information is not otherwise available.) The party requesting mediation must sign below. If both parties are requesting mediation, then both parties mu st sign. If domestic violence has occurred between the parties, the court cannot order mediation unl ess the victim agrees (by signing this motion, by filing a response agreeing to mediation, or by agreeing at a hearing). Date Signature Print Name Daytime Phone Mailing Address City State ZIP Date Signature Print Name Daytime Phone Mailing Address City State ZIP If Motion Is Signed By Only One Party If this motion is signed by only one party, the party who signs it must mail a copy of the motion to the other party. If the other party is represented by an attorney, the copy must be mailed to the attorney instead of to the party. The party who signs the motion must complete the following certificate so the co urt knows that the other party has been sent a copy. CERTIFICATE OF SERVICE I certify that on a copy of this motion was mailed to (print name of party or attorney): Signature: Notice to Party Not Signing Motion You have a right to respond to this motion. Your response must be filed with the court and a copy mailed to the other party no later than ten days from the date shown in the above certificate of service. Your respons e must state whether you agree to mediation or do not agree. If you do not agree, describe why you believe mediation is not appropriate. Include the case number in your response. A response form (DR-406) is available from the court. If you fail to file a response, the court may grant the request for mediation and schedule a mediation session. Page 2 of 2 Civ. R. 100 DR-405 (10/07)(st.3) AS 25.20.080 MOTION FOR MEDIATION AS 25.24.060 & .140