OFFICE OF DISPUTE RESOLUTION Civil Action #: _________________ _____________Court of _______________County Complainant: _________________________ Respondent: _______________________ Judge: _________________________ MEDIATOR’S REPORT I certify that a mediation session was conducted with the parties above on the ________ day of______________, 20_____ from ______ (am/pm) until _______ (am/pm) and the results of this mediation session are: 1. 2. _____ A full agreement was reached. _____ A partial agreement was reached. Remaining issues are as follows: ________________________________________________________________ ________________________________________________________________ 3. 4. _____ No agreement was reached. _____ The mediation is incomplete, therefore, _____ An additional session has been scheduled for the ______ day of __________________, 20 _____ at _____________(am/pm) Location: ___________________________________________ 5. 6. 7. _____ Please schedule another session. _____ No Show. ___________________________ appeared for the mediation session, however, ___________________________ did not appear at the scheduled time. _____ Other: ____________________________________________________ Compensation status for mediation services: _____ Paid in full _____ Payment is due from _______________ in the amount of $_________ _____Stipend from ADR Fund in the amount of $__________ _____ Pro Bono Case _____ Reimbursement for SDP in the amount of $______ Certificate(s) attached. _____ Other _____________________________________________________ ___________________________________ Complainant _________________________________ Respondent ___________________________________ Mediator’s Signature _________________________________ Date Return completed form to: Office of Dispute Resolution 308 10TH STREET COLUMBUS, GA 31901 American LegalNet, Inc. www.FormsWorkFlow.com