In the Circuit Court of County, Missouri



|In the Circuit Court of ________________ County, Missouri |

| | |

|_____________________________, | |

|Petitioner, | |

| |Case No. _______________________ |

| | |

|_____________________________, | |

|Respondent. | |

Certification at Case Management Conference

The undersigned hereby certify to the court as follows:

1. The status of undersigned’s compliance with Local Rule 68 is:

|Item |( if completed |Enter date to be completed: |

| | |(For Court use only) |

|Statement of Income and Expenses (Rule 68.4(1)) |( | |

|Statement of Assets and Debts (Rule 68.4(2)) |( | |

|Parenting Plan filed with court (Rule 68.7) (( not required) |( | |

|Form 14 exchanged (Rule 68.4(4)) (( not required) |( | |

|Required Document Production (Rule 68.4.1) |( | |

|Parent Education Program (Rule 68.6(1)) (( not required) |( | |

|ADR Education Program (Rule 68.6(2)) |( | |

2. There (( are)/ (( are no) allegations in the pleadings which require the appointment of a Guardian ad Litem for minor child(ren) involved in this case.

3. There (( are)/ (( are no) outstanding Order(s) of Protection involving the parties or a child of the parties.

4. There (( are)/ (( are no) objections to the case being assigned to mediation.

5. The parties have agreed that the case may be mediated by ________________________.

6. The undersigned’s contact information is as follows (Please print legibly):

|Name: |Telephone Number: |

|Mailing Address: |City: |State: |Zip: |

|Alternate Telephone Number: |E-mail Address: |

7. The undersigned’s attorney’s contact information is as follows (Please print legibly):

|Name: |Telephone Number: |

|Mailing Address: |City: |State: |Zip: |

|Alternate Telephone Number: |E-mail Address: |

| | |Party’s Signature: |

| | |Party’s Attorney’s Signature: |

| | |Date: |

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