Use this template/form to file for child custody in the state of NORTH CAROLINA
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
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
Name of Party Traveling in Excess of Fifty Miles Physical Address of Party (Include Street/City/ State) Approximate Number
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)