North Carolina Child Custody Form

File No.

STATE OF NORTH CAROLINA COUNTY OF CUMBERLAND

IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION Name Plaintiff

MOTION TO EXEMPT CHILD CUSTODY/VISITATION MEDIATION Cumberland County Child Custody/Visitation Mediation Rule 6

vs. Name Defendant

Name of Domestic Case Manager

Date of Mediation Hearing

MOTION TO EXEMPT CHILD CUSTODY/VISITATION MEDIATION The undersigned attorney/ party requests exemption of Child Custody/Visitation Mediation based upon the following reason(s): NOTE: Indicate with particularity the reason for request.

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _____________________________________________ Date

THIS MOTION IS TO BE FILED WITH THE FAMILY COURT ADMINISTRATOR’S OFFICE. Signature of Attorney/Party Address and Telephone Number

p Attorney for Plaintiff/ Pro Se

p Attorney for

Defendant/ProSe

CERTIFICATION NOTE: Complete this section if the reason stated above requests an exemption due to travel in excess of fifty miles.

I hereby certify that my physical place of residence is located in excess of fifty miles from the Cumberland County Courthouse. Name of Party Traveling in Excess of Fifty Miles

Physical Address of Party (Include Street/City/ State)

Approximate Number of Miles

ORDER The court having considered the request for exemption from Child Custody/ Visitation Mediation based upon the foregoing reasons orders that this case is:

p Exempt from Child Custody/Visitation Mediation. p NOT Exempt from Child Custody/Visitation Mediation. NOTICE: Exemption of Child Custody/Visitation Mediation does not exempt one or more parties from participating in the Parenting Education Sessions. Parties receiving an exemption due to the 50 mile plus rule must contact the Family Court Administrator for referral to an approved parenting education program. Date

CCLF-FC-010 (Rev. 11/00)

Signature of the District Court Judge