APPLICATION TO EXCUSE MANDATORY DIVORCE MEDIATION
Applies to new contested divorce cases only.  Do not use for paternity cases or divorce modifications.

Please complete this application to excuse mandatory divorce mediation to determine if your divorce mediation session can be excused for good
cause by the Administrative Office of the Courts Divorce Mediation Program.  The applicant must sign the form even if prepared by a third party.
 

Please Complete Information for Both Parties as listed on Petition

Case #:

Judge/Commissioner:

City Where Petition was filed:

Date Petition was Answered:

Full Name:____________________________________________________

Full Name:____________________________________________________

PETITIONER

RESPONDENT

Street Address:_________________________________________________

Street Address:_________________________________________________

City, State, Zip: ________________________________________________

City, State, Zip: ________________________________________________

Date of Birth: __________________________________________________

Date of Birth: __________________________________________________

E-mail Address:_________________________________________________

E-mail Address:_________________________________________________

Phone Number(s):_______________________________________________

Phone Number(s):_______________________________________________

Attorney’s Name:_______________________________________________

Attorney’s Name:_______________________________________________

Attorney’s Address:_____________________________________________

Attorney’s Address:_____________________________________________

Attorney’s City, State, Zip: ______________________________________

Attorney’s City, State, Zip: ______________________________________

Attorney’s Phone: ______________________________________________

Attorney’s Phone: ______________________________________________

Attorney’s E-mail: ______________________________________________

Attorney’s E-mail: ______________________________________________

Please circle

YES

YES

YES

NO

NO

NO

Is there a current Protective, Restraining or No Contact Order issued between the parties?  If yes, list
case #: ___________________

Is there a history or allegation of domestic violence?

Can you safely be contacted at the phone number or address listed above?  If not, how can you be
contacted? _____________________________________________________________________________ 

YES

NO

Is there a history of mental incapacitation regarding either party?  If yes, who?_____________________
What type? ____________________________________      Is it currently being treated? ______________

Please explain your reason for requesting to be excused from mandatory divorce mediation on the lines below.

STATEMENT OF VERIFICATION

 I verify under the penalties of perjury that the information provided on this application is true and correct
_________________________________________________
Applicant’s Signature

_________________________________________________
Date

 RETURN TO:      Bart MacKay, Program Coordinator
                          206 W. Tabernacle, Suite 160 
                          St. George, UT 84770

             Tel: (435) 986-5754            
             Email: divorceinfo@utcourts.gov

       02/28/17