Forms, Handouts, and Surveys

The forms listed below are in PDF format and can be downloaded or printed. Click a link below to open and view a form.

Waivers and Financial Forms

Application for Waiver of Mediation

There are reasons why mediation may not be appropriate in a case and why the court may excuse people from the order to mediate. Mediation may not be appropriate if you are uncomfortable being in the same room with the other person in the case, if you are afraid to speak up or disagree with them in mediation, if you are afraid that if you do speak up or disagree with them in mediation that you or your child(ren) might be harmed later. Mediation may also be inappropriate if a party has mental illness or a substance abuse issue so severe that participation in mediation might not be advisable. To apply, complete the Application for Waiver from Mediation form (PDF) and present it to the Clerk of Court’s office in your local courthouse. There are additional reasons mediation might not be appropriate. If you have any questions about this, please use our Contact Us page, call us at 319-248-1940, or reach us by email.

Application for Appointment of Reduced Rate Mediator

If you are low-income, you can apply to have a Reduced Rate Mediator appointed in your case. You and the other person in the case will need to apply separately using the Application for Appointment of Reduced Rate Mediator (PDF) and a form of proof of qualification as listed below.

You qualify if you can:

Provide proof that you are a current recipient of:

  • FIP
  • WIC
  • Food Stamps
  • Supplemental Security Income (SSI) from the Social Security Administration

OR

  • Provide proof that you are represented by Legal Aid Society or by a Volunteer Lawyers Project lawyer qualified for reduced fee services. Parties who meet the Iowa Legal Aid eligibility guidelines may also qualify.

OR

To apply, complete the Application for Appointment of Reduced Rate Mediator (PDF), get your proof, and present the application and the proof to the Clerk of Court’s office in your local courthouse. If it is determined that you qualify, a mediator will be assigned who will charge you a reduced fee for your share of the cost of mediation. Both individuals apply separately to qualify for the reduced fee.

Handouts and Surveys

Mediation Services of Eastern Iowa

319-248-1940 | admin@mediateiowa.org
509 Kirkwood Ave., Iowa City, IA 52240

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