1 DISTRICT COURT

CLARK COUNTY, NEVADA

2
PLAINTIFF NAME )
3 )
Plaintiff, ) Case No.: CASE NO.
4 )
vs. ) Dept. No: DEPT. NO.
5 )
DEFENDANT NAME )
6 )
Defendant. )
7 )

8 FMC REQUEST AND ORDER FOR MEDIATION NRS 3.475

9 In accordance with NRS 3.475, all individuals filing an answer to a complaint/motion for contested,
child-related divorce or post-divorce child-related issues are mandated to attend mediation toward the
10 resolution of custody/access issues. Upon the filing of this order, the plaintiff and defendant shall attend
mediation through the FMC court-connected program. The Family Mediation Center will contact both parties
11 using the information provided below. If this information is incorrect, the Court will be informed. The party
completing this form must make sure the other party is served and that the Family Mediation Center has
12 received a file-stamped copy.
If either party needs an interpreter, please list language: ________________________
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14 PLAINTIFF INFORMATION:
Name: __________________________ Home Phone: ___________________
15 Address: ________________________ Work Phone: ____________________
__________________________ Best time for appt? AM PM
16 Attorneys Name: _________________ Phone Number: __________________
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DEFENDANT INFORMATION:
18 Name: ___________________________ Home Phone: ___________________
Address: _________________________ Work Phone: ____________________
19 ___________________________ Best time for appt? AM PM
Attorneys Name: __________________ Phone Number: __________________
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21 CHILD(REN) INFORMATION [First & Last Name and Date of Birth (DOB)]:
Name: _________________DOB: _________ Name: ____________DOB:_________
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______________________________ ______________________________
23 Signature of Individual Completing this form Attorney Signature (if Applicable)
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Court Use Only
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Ordered and dated this DATE day of MONTH, YEAR.
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_________________________________
27 District Judge
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