Alternative Dispute Resolution Form

First name

Last name

Address

City

Zip code

Phone

Email

Gross annual income If known.

County your case is filed:   Franklin Jefferson Gadsden Leon Liberty Wakulla

Case Number Look on the Order for Mediation if unknown.

Do you and the party in question have attorneys?    Yes   No

If the answer to the question about was next please fill out the following information:

Your attorneys name

Your attorneys phone

Other attorneys name

Other attorneys phone

Has there ever been domestic violence between you and the other party?    Yes   No

Do you and the party in question have children together?    Yes   No

If the answer to the question about was next please fill out the following information:

Childs name   Childs birthdate
Childs age   Female Male

Childs name   Childs birthdate
Childs age   Female Male

Childs name   Childs birthdate
Childs age   Female Male

Childs name   Childs birthdate
Childs age   Female Male

Has either you or the other party gone to the Department of Revenue for help with child support?    Yes   No

If the answer to the question above is yes then please tell us when:

Is DOR representing the case: Yes   No

Is there any thing else you would like us to know:

You will then be contacted with some possible dates for the mediation either by phone or letter. Our office will then coordinate a date with the other party.