Law Block III Family Law Assignment –

Template 2 – Request for Mediation

IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT,

IN AND FOR MIAMI-DADE COUNTY, FLORIDA

Case No.: 175678FC-02

Division: Family
PAULI POLK,
Petitioner,

and

SAM SAMUELS,
Respondent.

______________________________________________________________________________

MOTION FOR REFERRAL TO MEDIATION

___x__ Petitioner _____ Respondent requests that the Court enter an order of referral to
mediation, and states:

(1) This is a divorce proceeding and the parties are unable to reach agreement on the
following issues of: substantial assets, including three homes, retirement accounts, and
savings.

(2) The undersigned believes that without immediate intervention of a mediator that the
dispute will heighten and the parties have been unable to reach agreement on a
mediator.

(3) The undersigned request the matter be immediately referred to mediation and for the
Court to appoint a mediator to facilitate the resolution of this case.

I certify that a copy of this document was 9. ( x ) mailed ( ) faxed and mailed ( x ) e-mailed (
) hand-delivered to the person(s) listed below on March 13, 2022.

11. Other party or his/her attorney:

Name: Sam Samuels
8855 Cardinal Lane
Miami, Florida, 33023
Tel: 978-659-4387
samsamuels@live.com

___________________________________
Pauli Polk

Pauli Polk
8597 Cardinal Lane,
Miami, Florida, 33021.
Tel: 978-322-5137
Fax: 978-865-5137
paulipolk@yahoo.com

IF A NON-LAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN
THE BLANKS BELOW: n/a
[fill in all blanks] This form was prepared for the _____ Petitioner _____ Respondent.
This form was completed with the assistance of:
{name of individual}, ___________________________________________________________,
{name of
business}_____________________________________________________________________,
{address}
____________________________________________________________________________,
{city}_______________,{state} _____, {zip code}_________,{telephone number}__________.