Page 135 — Imperial — Local Rules July 2026

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 W. Main Street El Centro, CA 92243 PETITIONER: RESPONDENT: STIPULATION FOR MEDIATION CASE NUMBER:

Provide any of the following case numbers: Family Law: _____________________ Family Support: _______________________ Domestic Violence: _______________ Uniform Parentage Action:______________
A dispute exists between the above named parties concerning (check all that apply and provide a brief explanation): Custody Visitation Other
Date of last Mediation Report: //______.
Do you have a current Domestic Violence Restraining Order? Yes (If yes, attach copy) No Please provide the following information. (Post Office Box if Domestic Violence is an issue.)

PETITIONER’S INFORMATION: RESPONDENT’S INFORMATION:
Name: Name:
Mailing Address: Mailing Address:
City State/Zip: City State/Zip:
Home Phone: Work Phone: Home Phone: Work Phone:
Relationship to child: Relationship to child:
Language: Language:
Attorney: Attorney:

Any information I have provided above and any attachment to this request is furnished in good faith in the hope of settling the dispute. I declare under penalty of perjury that the foregoing is true and correct.

PETITIONER SIGNATURE AND DATE RESPONDENT- SIGNATURE AND DATE

Notice of Mediation Appointment: Superior Court, Family Law, Clerk’s Office Date: _________ Time: ___________ 939 Main Street, Lower Level, El Centro, CA

CLERK SIGNATURE

Form Approved for Optional Use imperial.courts.ca.gov FL-05 (Adopted 07/01/07, Revised 07/01/08, 01/01/11, 01/01/12, 01/01/13, 01/01/15) STIPULATION FOR MEDIATION