MEDIATION & DIVERSION SERVICES FAMILY/TEMPORARY RELIEF REQUEST FORM
800 East Twiggs Street, Room 208, Tampa, FL 33602-4024 Phone (813) 272-5642 Fax (813) 301 -3705 E-Mail: [email protected]
*PLEASE NOTE* TO PROCESS YOUR REQUEST YOU MUST SUPPLY OUR OFFICE WITH A COPY OF THE PETITION, LAST COURT ORDER OR FINAL JUDGMENT.
YOUR NAME: DATE: CASE# DIVISION: #MINOR CHILDREN:
CASE STYLE first filed): (Title of Case when Type: __ Dissolution of Marriage __ Paternity
Petitioner __ Department of Revenue (DOR)
vs Status: (choose one): I Respondent __ Pre-Judgment- new case; not finalized; no order or judgment
Post-Judgment- old case; judgment already entered
PETITIONER's name: Address:
City: State Zipcode
Phone: H ( ) B( ) C(____}
E-Mail:
ATTORNEY's name: Address:
City: State Zip code
Phone: B ( ) F ( ) C( )
E-Mail:
MEDIATION ISSUES __ Child Support __ Visitation __ Medical __ Paternity __ Marital Home __ Primary Residence/Custody
__ Alimony/Spousal Support __ Attorney's Fees & Costs __ Equitable Distribution (debts & assets) __ Other _____ All Issues
Address: ____________RESPONDENT's name:
Cit: State· Zi code
______________ Phone: H ( __ ~--. _______ B ( _
yes, this interfere with your
parties?
_______ ________________ _
___, __________ c (____}
E-Mail: ----------------------------------------------------------
ATTORNEY's name: Address:
Cit· State: Zi code:
Phone: B ( F ( C(
E-Mail:
CIRCLE ALL THAT APPLY: IS SECURITY NEEDED? Yes No
Is there a history of domestic violence? Yes No
If will ability to mediate? Yes No
Is there a juvenile dependency case pending involving these Yes No
Does either party have an Order for Indigence or mediation fees waived? Yes* No
*If yes, circle party(ies) involved and attach copy of the order: father/husband mother/wife
SCHEDULING INFORMATION- ATTORNEYS ONLY:
Check the type of mediation below; coordinate with opposing side & choose any business day at 9:00 am, 11:30 am, or 2:30 pm.
*Non-Court ordered requests: If both parties are not represented by counsel our office must first send a 10 day request letter to the
pro se party. (Provide copy of order)
__ Temporary Relief __ Court Order/date: _____ _ Non-Court Ordered
date 1 sr CHOICE time date 2ND CHOICE time date 3'd CHOICE time date 41h CHOICE time
Limited Availability for PLANT CITY (Division R cases only)- Mondays - 9:00, 11:30 am & 2:30pm; Thursdays- 9:00, 11:30 am & 2:30pm
CONTACTPERSON: ______________ ~Ph~o~n~e ________ ~D~a~te
·Upon receipt of this completed form a Court Program Specialist will contact your office for confirmation.
Revised 5/2412013
