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Utah Application to Excuse Mandatory Divorce Mediation Form

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Utah Application to Excuse Mandatory Divorce Mediation Form
Utah Application to Excuse Mandatory Divorce Mediation Form
APPLICATION TO EXCUSE MANDATORY DIVORCE MEDIATION
Applies to new contested divorce cases only. Do not use for paternity cases or divorce modifications.
Please complete this application to excuse mandatory divorce mediation to determine if your divorce mediation session can be excused for good
cause by the Administrative Office of the Courts Divorce Mediation Program. The applicant must sign the form even if prepared by a third party.
Please Complete Information for Both Parties as listed on Petition
Case #: Judge/Commissioner: City Where Petition was filed: Date Petition was Answered:
PETITIONER
Full Name:____________________________________________________
Street Address:_________________________________________________
City, State, Zip: ________________________________________________
Date of Birth: __________________________________________________
E-mail Address:_________________________________________________
Phone Number(s):_______________________________________________
Attorney’s Name:_______________________________________________
Attorney’s Address:_____________________________________________
Attorney’s City, State, Zip: ______________________________________
Attorney’s Phone: ______________________________________________
Attorney’s E-mail: ______________________________________________
RESPONDENT
Full Name:____________________________________________________
Street Address:_________________________________________________
City, State, Zip: ________________________________________________
Date of Birth: __________________________________________________
E-mail Address:_________________________________________________
Phone Number(s):_______________________________________________
Attorney’s Name:_______________________________________________
Attorney’s Address:_____________________________________________
Attorney’s City, State, Zip: ______________________________________
Attorney’s Phone: ______________________________________________
Attorney’s E-mail: ______________________________________________
Please circle
Is there a current Protective, Restraining or No Contact Order issued between the parties If yes, list
case #: ___________________
YES NO
YES NO Is there a history or allegation of domestic violence
YES NO Can you safely be contacted at the phone number or address listed above If not, how can you be
contacted _____________________________________________________________________________
YES NO Is there a history of mental incapacitation regarding either party If yes, who_____________________
What type ____________________________________ Is it currently being treated ______________
Please explain your reason for requesting to be excused from mandatory divorce mediation on the lines below.
_________________________________________________ _________________________________________________
Applicant’s Signature Date
DEMOGRAPHIC SURVEY INFORMATION
RACE (Please check only one) - Participation in the demographic survey is entirely voluntary and will be used for reporting purposes only.
9 American Indian or Alaska Native 9 Caucasian 9 African American 9 Other/Don’t Know
9 Asian / Asian American 9 Hispanic 9 Native Hawaiian / Other Pacific Islander
RETURN TO: Bart MacKay, Program Coordinator
206 W. Tabernacle, Suite 160
St. George, UT 84770
Tel: (435) 986-5754
Fax: (435) 986-5759
Email: divorceinf[email protected]
Utah Application to Excuse Mandatory Divorce Mediation Form