Placer — Self-Help Settlement Services Appt. Request

Source: https://www.placer.courts.ca.gov/sites/default/files/pl-fl024t_0.pdf

SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER Superior Court of California, County of Placer FOR COURT USE ONLY

I ☐ 10820 Justice Center Drive P. O. Box 619072 Roseville, CA 95661-9072

Petitioner/Attorney name:

Phone number (print clearly): Email address (print clearly): Mailing address (print clearly):

Respondent/Attorney name:

Phone number (print clearly): Email address (print clearly): Mailing address (print clearly):

CASE NUMBER: AGREEMENT TO SCHEDULE VIDEO SELF-HELP
SETTLEMENT SERVICES APPOINTMENT

Parties represented by an attorney may only participate in the Video Self-Help Settlement Services if the other party is self-represented (represents themselves). We are agreeing to participate in the Video Self- Help Settlement Services and request a video settlement services appointment. We request an appointment on any of the dates/times that are listed below. We agree and understand the appointment will be by video. We understand the appointment will be confirmed via email and the email will include an internet link for each party to enter the video appointment.

1. Is either party in this case represented by an attorney? ☐ Neither party ☐ Petitioner ☐ Respondent a. Name of attorney: _____________________________________________________________________
2. Are you seeking help to settle your dissolution or legal separation case? ☐ Yes ☐ No
3. If yes, have both parties completed their preliminary Declarations of Disclosure? ☐ Yes ☐ No
4. If no, for what type of case are you seeking a video settlement services? _______________________________

Is there a current Domestic Violence Restraining Order? If so, what is the date of the most recent order? _________ What issues do you want to discuss at the video settlement appointment: ☐ Property/Debts ☐ Spousal Support ☐ Child Support ☐ Other______________________________________

List five dates and times that all parties agree to participate:

1. ________________________________________ Time: ☐ 10:30am ☐ 1:30pm
2. ________________________________________ Time: ☐ 10:30am ☐ 1:30pm
3. ________________________________________ Time: ☐ 10:30am ☐ 1:30pm
4. ________________________________________ Time: ☐ 10:30am ☐ 1:30pm
5. ________________________________________ Time: ☐ 10:30am ☐ 1:30pm

Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 1 of 2 Form No. PL-FL024T Effective 05-18-2020

☐ I acknowledge that the purpose of the video settlement appointment is to reach an agreement in my family law case. I understand that we cannot address child custody/visitation or domestic violence issues. ☐ I understand that the Settlement Officer for this appointment will be a Court Self-Help staff member. ☐ I agree to participate in a video settlement discussion to resolve either a part of or all of my family law case unrelated to child custody/visitation or domestic violence.

☐ I agree that if there is an unexpected reason why I cannot make my appointment I will immediately call the other party and the Self-Help Center to let them know of the cancellation.

☐ I understand I may have to reschedule the appointment to the next date and time that is available for all parties and the Settlement Office.

I acknowledge and confirm the above by my signature below.

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Petitioner Date Respondent Date

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Attorney for Petitioner Date Attorney for Respondent Date

FOR COURT USE ONLY

Date Received: ☐ Eligible ☐ Ineligible - Reason: Appointment Date: Confirmation Sent: ☐ E mailed ☐ Mailed ☐ In Person

Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 2 of 2 Form No. PL-FL024T Effective 05-18-2020