Santa Barbara — SC-4017*

Source: https://www.santabarbara.courts.ca.gov/system/files/forms-and-filings/sc4017.pdf

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ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address): TELEPHONE NO.: FOR COURT USE ONLY

EMAIL ADDRESS (Optional) ATTORNEY FOR (NAME):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA

Santa Barbara–Anacapa Santa Maria-Cook Lompoc Division
1100 Anacapa Street 312-C East Cook Street 115 Civic Center Plaza

Santa Barbara, CA 93101 Santa Maria, CA 93454 Lompoc, CA 93436

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT:

NOTICE OF CANCELLATION OF MEDIATION CASE NUMBER:
AND STATEMENT OF GOOD CAUSE
(Local Rule 1501 et. seq., Family Code §3170)

Mediation date: Mediation time: Mediation place: Family Court Services

1100 Anacapa Street, Santa Barbara, CA 93101 312 East Cook Street, Santa Maria, CA 93454

To: (Name of other parent and opposing counsel, if applicable)

NOTICE: The Family Custody Services mediation appointment set for (date) at (time) a.m p.m. HAS BEEN CANCELLED for the following good cause reason(s)

(state your good cause reason(s)):

The cancellation of the mediation is based on good cause, or the Court may order monetary or other sanctions against the cancelling parent.

DECLARATION OF COMPLIANCE WITH REQUIREMENT
TO GIVE NOTICE OF THE CANCELLATION AND TO RESCHEDULE

I, , declare (check the appropriate boxes):

1. I am self- represented or

2. I am an attorney and I represent Petitioner Respondent Other:

Mandatory Form SC-4017 [Rev. March 2025] NOTICE OF CANCELLATION OF MEDIATION Local Rule 1501FCet.§3170seq., AND STATEMENT OF GOOD CAUSE Page 1 of 2

Insert Case Name: CASE NUMBER:

3. I understand that I am required to cooperate with the other parent and the attorney for the other
parent, if retained, in order to: (a) schedule, (b) cancel or (c) reschedule a mediation appointment.

4. I also understand that I can only cancel a mediation appointment for good cause.

5. I have communicated with the other parent or the attorney for the other parent, if retained. We have
agreed to reschedule the mediation appointment. I will serve on the other parent and file a new
Notice of Mediation form (SC-4018).

6. I have attempted to provide Notice of Cancellation and/or to reschedule the mediation appointment,
but was not successful because:

(Statement of attempts to contact opposing party directly to cancel and reschedule, including details such as date, time, phone number(s) called, letters written, faxes or email sent.)

See additional facts stated on separate paper labeled as Attachment 5 and attached to this Notice.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and

correct.

SIGN

DATED: SIGNED:

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Mandatory Form SC-4017 [Rev. March 2025] NOTICE OF CANCELLATION OF MEDIATION Local Rule 1501FCet.§3170seq., AND STATEMENT OF GOOD CAUSE Page 2 of 2