Missouri Form 15 – Fill Out and Use This PDF

IN THE THIRTEENTH JUDICIAL CIRCUIT COURT OF MISSOURI

FAMILY COURT DIVISION

In re the Matter of
__________________________
Petitioner
and	Case No.:
__________________________
Respondent
	FORM 15

Form 15 must be completed by Petitioner and filed no later than 60 days from the date of service, when a dissolution or motion to modify involves children.

Check all that apply:

1.____ The parties have completed two hours of Rule 68.12 mediation as verified by the Notice of Mandatory Mediation Compliance.

2.____ The parties have no disputes regarding parenting issues regarding the children.

3.____ The required mediation under Rule 68.12 has been waived by order of the Court.

IF YOU HAVE SELECTED 1, 2, OR 3 ABOVE, YOU NEED ONLY SIGN THE AFFIDAVIT BELOW AND FILE FORM 15. IF YOU CANNOT SELECT 1, 2 OR 3

ABOVE, PLEASE CONTINUE.

4.____ The parties have a dispute regarding parenting issues and have not been to a mediator:

a._____	Parties request court appointed mediator
b._____	Parties request ________________________________be appointed mediator
	Mediator’s Address ________________________________
	Mediator’s Telephone ______________________________
c._____	Parties request MARCH mediation services (paternity cases, family access motions, and
	post-dissolution motions qualify for MARCH mediation services)

5.____ There has been or there is a current Restraining Order or Protection From Abuse Order involving the parties or the child.

The Petitioner’s mailing address is:	The Respondent’s mailing address is:
___________________________________	_________________________________
___________________________________	_________________________________
___________________________________	_________________________________
Attorney for the Petitioner is:	Attorney for the Respondent is:
Name_______________________________	Name______________________________
Address_____________________________	Address____________________________
Phone______________Fax______________	Phone_________________Fax__________

AFFIDAVIT

I hereby certify that the above Response to Rule 68.12 Mediation of Child Custody and Visitation Disputes is complete, true and accurate to the best of my knowledge and belief.

_______________________________________________________

Affiant- Petitioner/Respondent

Certificate of mailing: I hereby certify that a copy of the above and foregoing was mailed on this _____day of

_______________, 20__,

Signature:__________________________________________________________________________

[Effective July 1, 2003]