NORTH CAROLINA Child Custody Form

Use this template/form to file for child custody in the state of NORTH CAROLINA

north-carolina-child-custody-form

Text version of this Form

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STATE OF NORTH CAROLINA File No.

COUNTY OF CUMBERLAND

IN THE GENERAL COURT OF JUSTICE

DISTRICT COURT DIVISION

Name Plaintiff MOTION TO EXEMPT

CHILD CUSTODY/VISITATION MEDIATION

vs. Cumberland County Child Custody/Visitation Mediation Rule 6

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.

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_____________________________________________

THIS MOTION IS TO BE FILED WITH THE FAMILY COURT ADMINISTRATOR’S OFFICE.

Date 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 Signature of the District Court Judge

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