MASON COUNTY LCR 40 (B) 2.4.5 - APPENDIX B

MASON COUNTY LCR 40 (b) 2.4.5 - APPENDIX B

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DO NOT FILE WITH THE COURT ______

SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF MASON

IN RE ) ) ______, ) ) Petitioner, ) NO. ______) and ) FAMILY LAW MEDIATION STATEMENT ) ______, ) [ATTENTION CLERKS: This document is not ) to be made a part of the court file.] Respondent. ) )

Pursuant to LCR 40 (b) 2.4.5, in family law actions, all parties shall prepare and deliver a mediation statement to the mediator, opposing party, and to the State of Washington, if the State is a party, no later than five working days prior to the mediation. The statement shall address the following matters if they apply to the case:

1. General Information:

1.1 Personal Data:

Name: ______Date of Birth: Employer, occupation or former occupation: ______

1.2 Marriage and Separation Data:

Date of Marriage ______Date of Separation ______

1.3 Children:

______Age ______DOB ______Age ______DOB ______Age ______DOB ______

FAMILY LAW MEDIATION STATEMENT- 1 ______Age ______DOB ______

2. Issues Remaining in Dispute: [Check only those boxes which apply.]

[ ] Parenting Plan* [ ] Child Support** [ ] Spousal Maintenance [ ] Attorney Fees [ ] Division of Property [ ] Division of Debts [ ] Division of Retirement/Pension [ ] Other: ______

* Provide a copy of any agreed Parenting Plan. ** A copy of any agreed Order of Child Support, worksheets and income information shall be provided as forth below in paragraph 14, even if the parties have agreed to a child support amount.

3. Community Assets:

4. Separate Assets:

5. Community Debts:

6. Separate Debts:

FAMILY LAW MEDIATION STATEMENT- 2 7. Attorney Fees:

8. Proposed Parenting Plan:

8.1 Primary Residential Parent:

8.2 Alternate Residential Schedule:

8.3 Basis for Restrictions, if any:

8.4 Decision-making:

FAMILY LAW MEDIATION STATEMENT- 3 8.5 Alternative Dispute Resolution:

8.6 Miscellaneous Requests:

9. Income and Proposed Child Support (including any reasons for deviation from schedule amount):

NOTE: UNLESS OTHERWISE AGREED, THE FOLLOWING WILL BE ASSUMED: (1) Each parent shall name the child(ren) as insured on health care insurance available through the parent’s employment or union, provided that the cost of the insurance does not exceed 25% of the parent’s basic support set out on the support schedule worksheet; and (2) Each party shall be responsible for his or her proportionate share (set out on the support schedule worksheet) of the child(ren)’s uninsured health care expenses and verified work-related child care expenses; and (3) Child support shall be terminated at age 18 or upon graduation from high school, whichever is later; and (4) The Court shall retain jurisdiction to review the issue of post-secondary school support; and (5) The support obligation will be paid through the Washington State Support Registry; and (6) Child support is due by the last day of each month.

10. Proposed Property and Debt Division:

Fair Market Debt Owed Net to Net to Wife Value Husband

FAMILY LAW MEDIATION STATEMENT- 4 REAL ESTATE $ $ $ $ $ $ $ $ VEHICLES (Year/Make) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ HOUSEHOLD GOODS $ $ $ $ TOOLS/EQUIPMENT $ $ $ $ RECREATIONAL/HOBBY EQUIP. $ $ $ $ BUSINESS/PROFESSION $ $ $ $ STOCKS/BONDS $ $ $ $ LIFE INS. CASH VALUE $ $ $ $ RETIREMENT/IRAs $ $ $ $ OTHER ASSETS/RECEIVABLES $ $ $ $ TOTAL OTHER DEBT $ $ $ $ TOTALS $ $ $ $ 11. Proposed Spousal Maintenance:

11.1 Reason for Request:

11.2 Proposed Amount and Length of Time Spousal Maintenance should Continue:

12. Proposed Division of Attorney's Fees and Costs:

13. Other:

FAMILY LAW MEDIATION STATEMENT- 5 14. Documents to be attached:

• Child Support Worksheets. In all cases involving child support issues, completed child support worksheets and proposed child support order. Document(s) attached as Exhibit A: ______Yes ______No If no, please explain:

• Federal Income Tax Returns. Copies of federal income tax returns, with schedules and W-2 forms, for the preceding three (3) tax years. Document(s) attached as Exhibit B: ______Yes ______No If no, please explain:

• Payroll Statements. Copies of payroll statements from employers for the last six months. Document(s) attached as Exhibit C: ______Yes ______No If no, please explain:

• Real Estate. A copy of an appraisal or market analysis for each parcel, and a copy of the most recent statement of balances due on mortgages, real estate purchase contracts, deeds of trust, or other debt secured by the real property. Document(s) attached as Exhibit D: ______Yes ______No If no, please explain:

• Pension Plans and Retirement Accounts. The most recent employer's pension statement, and documentation of contributions since the date of that statement, of any pension plan of either party if pension division by a QDRO is proposed; otherwise, provide a statement of present value of the retirement benefits. The most recent statement of all 401K, deferred compensation or other similar account(s). Document(s) attached as Exhibit E: ______Yes ______No If no, please explain: • Personal Property Appraisals. A written appraisal of any antiques, jewelry, or other items of special, unusual or extraordinary value or a summary of the evidence that will be relied upon. Document(s) attached as Exhibit F: ______Yes ______No If no, please explain:

• Automobile Values. A copy of the most recent N.A.D.A. Official Used Car Guide or other appraisal guide showing both average loan or wholesale and retail values for any automobiles. Document(s) attached as Exhibit G: ______Yes ______No If no, please explain:

• Life Insurance. A statement from each life insurance company issuing a policy of insurance on the life of either party as to its cash value

FAMILY LAW MEDIATION STATEMENT- 6 and any loans against the cash value. Document(s) attached as Exhibit I: ______Yes ______No If no, please explain:

• Business Valuation. A written appraisal of any sole proprietorship, partnership, or closely held corporation of either or both the parties, or a summary of the evidence that will be relied upon. Document(s) attached as Exhibit J: ______Yes ______No If no, please explain:

• Separate Property and Debt Tracing. A summary of the source and tracing of any property asserted to be the separate property or obligation asserted to be the separate obligation of either party, and any community interests in separate property, or a summary of the evidence that will be relied upon. Document(s) attached as Exhibit H: ______Yes ______No If no, please explain:

• Debts. A list of debts as of the date of separation, including minimum monthly payments. Document(s) attached as Exhibit I: ______Yes ______No If no, please explain:

DATED this ____ day of ______, ______.

______Attorney for ______/ Pro Se Address: ______

Copies Provided To:

NAME ______NAME ______Attorney for ______/ Pro Se Attorney for ______/ Pro Se Address ______Address ______

FAMILY LAW MEDIATION STATEMENT- 7 NAME ______NAME ______Attorney for ______/ Pro Se Attorney for ______/ Pro Se Address ______Address ______

FAMILY LAW MEDIATION STATEMENT- 8