FORM C. FAMILY MEDIATION PROGRAM FEE REDUCTION REQUEST

Date: ____________________

Name of Party Requesting Reduction/Waiver: ________________________

Case Number: _________________________________________

Please attach all of the following in order to have your case considered for further mediation sessions that are provided financially in whole or part by the family mediation program:

(1) your most recent W2 form;

(2) your most recent tax return;

(3) proof of income from your current employers for the past 12 months;

(4) the name and age of all children living with you or for whom you pay child support; provide a copy of any court order for child support, spousal support, medical and other insurance for the children, and day care expenses.

(5) any other documentation as required by the family mediation program administrator.

Once the family mediation program administrator has made a determination of your eligibility to pay for mediation services, you will be notified of the decision. You may be required to pay in full or part for the mediation services. The mediator in your case will provide you with an invoice if appropriate, and you are required to pay for mediation services rendered if ineligible for fee reduction.

Under penalty of perjury, I agree that I have provided full and truthful disclosure and evidence of my financial condition.

________________ ______________________________

Date Name (print)

Signature: ______________________________