171 - 327 (R ev. 12 / 17 ) IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT, LAKE COUNTY, ILLINOIS IN THE MATTER OF ) ) ) ) ) Gen No. ) ) Name of Mediator : Referring Judge : (Check Appropriate Boxes) 1. Conflict of Interest Full Caseload Parties failed to meet terms of engagement The parties have not completed the initial orientation process. Other: 2 . The following mediation sessions were conducted: Date of Session Duration of Session Those in Attendance 3. Mediation was terminated without an agreement. 4. Additional mediation sessions are recommended. 5. A written agreement was reached by the parties on some or all of the issues and a copy of the signed agreement is attached to this report. 6. I charged $ for the mediation services provided to the parties. My fee has been paid in full. owes a balance of: $as of the date of . and/or owes a balance of: $ as of the date of . I request that the court order the parties to pay their outstanding balance, or set a hearing on the disputed amount. Respectfully submitted, Date: Name: Address: Phone: Email: Copies must be sent to the attorney(s) of record and to any unrepresented parties. Copies sent to the following: American LegalNet, Inc. www.FormsWorkFlow.com