ORDER
FMCODISTRICT COURTFAMILY DIVISIONCLARK COUNTY, NEVADAPlaintiff)) Case No. -vs-)) Department Defendant)) FAMILY MEDIATION CENTER (FMC) REQUEST AND ORDER FOR MEDIATION – NRS 3.475Pursuant to Nevada Revised Statute 3.475 the district court shall establish a program of mandatory mediation in cases that involve the custody or visitation of a child. Once this request is submitted to FMC, a mediation appointment will be scheduled. FMC will send notice of the scheduled mediation appointment to both parties using the information provided below. Please print as clearly as possible.The party completing this request must make sure that a copy signed by the judge is sent to the other party by certified mail or return receipt requested mail and that a file-stamped copy is delivered to FMC. If the party completing this request does not appear for the initial mediation appointment, FMC will close its case.Printed Name of Party Completing this Request: Non-financial issue(s) that need(s) to be mediated: (Check all that apply) Legal Custody Timeshare (physical custody) Vacation Holidays & celebrations Transportation & exchangesIf either party needs an interpreter, language must be listed:PLAINTIFF INFORMATION:Name:Cell Phone:Address:Home Phone:Best time for appt? AM □ PM □Email:Best day for appt? (M-F)Attorney’s Name:Atty’s Number:DEFENDANT INFORMATION:Name:Cell Phone:AddressHome Phone:Best time for appt? AM □ PM □Email:Best day for appt? (M-F)Attorney’s Name:Atty’s Number:CHILD(REN) INFORMATION [First & Last Name and Date of Birth (DOB)]:Name:DOB:Name:DOB:Name:DOB:Name:DOB:Court Use OnlyOrdered and dated this _____ day of ______________, 20___.District JudgeINSTRUCTIONS FOR COMPLETING THEREQUEST AND ORDER FOR MEDIATION(These instructions were developed by FMC to assist in preparing theRequest and Order and moving it through the correct channels in a timely manner.)Please read these instructions carefully before completing the request:1.The request must be filled out completely. The Plaintiff and Defendant will be the same as all your original court documents. Complete and correct mailing and e-mail addresses on both parties are mandatory. The date and signature line for the judge are the only items that need to be left blank.2.Once the request is completed, take it to the third floor of the Family Courts and Services building. Place the form in the correct department’s box.3.To have the request returned to you as quickly as possible, once the form is signed by the judge, you must pick it up. Place a note on the request informing the department that you will pick it up once it is signed. When you pick up the signed form, take it to the kiosk on the first floor of the Family Courts and Services building to file the request electronically. A file-stamped copy will be provided to you.4.Once you receive the file-stamped copy, you must bring it to FMC and complete a FMC Data Sheet so that a mediation appointment can be scheduled. You must also send a copy of the file-stamped request by certified mail or return receipt requested mail to the other party. ................
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