IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI
FAMILY COURT DIVISION
__ at Kansas City __ at Independence
In re the Matter of
___________________________________________
Petitioner
and Case No. _______________________________
___________________________________________
Respondent
PETITIONER/RESPONDENT'S RESPONSE TO RULE 68.12
NOTIFICATION OF CHILD CUSTODY AND RELATED PARENTING ISSUES
Form 15 must be completed by each party and filed no later than 45 days from the date of service, when a
dissolution or motion to modify involves children.
Check all that apply:
1. __ The parties have completed two hours of Rule 68.12 mediation as verified by the Notice of Mandatory
Mediation Compliance.
2. __ The parties have no disputes regarding parenting issues regarding the children.
3. __ The required mediation under Rule 68.12 has been waived by order of the Court.
IF YOU HAVE SELECTED 1, 2, OR 3 ABOVE, YOU NEED ONLY SIGN THE AFFIDAVIT BELOW AND FILE
FORM 15. IF YOU CANNOT SELECT 1, 2 OR 3 ABOVE, PLEASE CONTINUE.
4. __ The parties have a dispute regarding parenting issues and have not been to a mediator qualified under Missouri
Supreme Court Rule 88.05.
5. __ There has been or there is a current Restraining Order or Protection From Abuse Order involving the parties or
the child.
The petitioner's total monthly gross income from wages and additional income is $ ___________.
The respondent's total monthly gross income from wages and additional income is $ ___________.
The Petitioner's mailing address is:
__________________________________________
__________________________________________
Phone:____________________________________
Attorney for the petitioner is:
Name: __________________________________
Address _________________________________
________________________________________
Phone __________________________________
The Respondent’s mailing address is:
________________________________________
________________________________________
Phone:__________________________________
Attorney for the Respondent is:
Name: __________________________________
Address _________________________________
________________________________________
________________________________________
AFFIDAVIT
I certify that the above Response to Rule 68.12 Notification of Child Custody and Related Parenting
Issues is complete, true and accurate to the best of my knowledge and belief.
___________________________________
Affiant--Petitioner/Respondent
Subscribed and sworn to before me the undersigned Notary Public, on _____________, _____.
My Commission Expires: ___________________________________
NOTARY PUBLIC
File original with the Jackson County Courthouse: Civil Records-Third Floor, 415 E. 12th, Kansas City, MO 64106 or
Judicial Records, 308 W. Kansas, Independence, MO 64050.
Certificate of mailing: I hereby certify that a copy of the above and foregoing was mailed/faxed on this ___ day
of__________, ______, to: Family Court Resource Services, 103 N. Main, Suite 200, Independence, MO 64050
Phone:(816) 881-1814/Email: sue.mills@courts.mo.gov Signature ________________________________________
Form 15 12/08
