mediation diversion services family/temporary · pdf filemediation & diversion services...

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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 4 1 h 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: ______________ ________ ·Upon receipt of this completed form a Court Program Specialist will contact your office for confirmation. Revised 5/2412013

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Page 1: MEDIATION DIVERSION SERVICES FAMILY/TEMPORARY · PDF fileMEDIATION & DIVERSION SERVICES FAMILY/TEMPORARY RELIEF REQUEST FORM 800 East Twiggs Street, Room 208, Tampa, FL 33602-4024

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