16 February 2011

This form is to be used in connection with family proceedings to which Practice Direction 3A applies. It should be completed in accordance with the Pre-application

Protocol annexed to the Practice Direction and be filed with the court with any application made in proceedings to which the Practice Direction applies.

Where either Part 1 or Part 2 applies, the form must be completed and signed by the mediator concerned and counter-signed by the applicant or the applicant's legal representative.

Where either Part 3 or Part 4 applies, the form must be completed and signed by the applicant or the applicant's legal representative.

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