NHJB-2630-DFP (05/01/2019) (for court use only) Total Authorized for Payment: $ Approval initials THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) MEDIATOR STATEMENT FOR PAYMENT 1. Name of payee Mediator name (if different from payee) Address of payee Vendor number 2. I filed a Mediation Report for the session held on , and seek payment as follows: Type of Case: I represent that the foregoing is a true and reasonable bill for the services I rendered. I certify that I have not and will not receive any other compensation for the services specified. Date Signature of Mediator Printed Name of Mediator Bill for services must be submitted to the court within 7 days of mediating the case. A separate form is required for each case mediated. American LegalNet, Inc. www.FormsWorkFlow.com