Santa Clara — FM-1072*

Source: https://santaclara.courts.ca.gov/system/files/forms/fm-1072_rem.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA FOR COURT USE ONLY STREET ADDRESS: 201 North First Street, San José, CA 95113 MAILING ADDRESS: 191 North First Street To keep other people from CITY AND ZIP CODE: San José, California 95113 seeing what you entered on BRANCH NAME: Family Justice Center your form, please press the PETITIONER: Reset Form button at the end of this form when finished.

RESPONDENT:

CASE NUMBER:

WAIVER OF RIGHT TO INDIVIDUAL SESSIONS FCS NUMBER:

I, , have declared I am /have been a victim of (Print your Name) Domestic Violence, or have a protective order. I have been informed and I understand that I

have the option to meet with the mediator separately from the other parent and at separate

times. I decline that option and wish to be seen together with the other parent.

Signature: Date:

I, , have completed the differential Domestic

Violence Assessment and have met with the parents separately.

Signature: Date:

Reset Form

FM-1072 REV 11/25/08 WAIVER OF RIGHT TO INDIVIDUAL SESSIONS Page 1 of 1