THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) REQUEST FOR MEDIATION PAYMENT FROM MEDIATION FUND (With Repayment to Office of Cost Containment) IMPORTANT: You must also complete the Financial Affidavit of Assets and Liabilities (NHJB-2065-FS) AND the Child Support Guidelines Worksheet (NHJB-2101-FS) and file them with this form. 1. Applicant's Name: I am a party to a parenting case OR I am a party to a divorce case with minor children OR I am a party to a previously closed divorce OR parenting case which has been brought forward and reopened for modification or enforcement of prior court orders regarding minor children. 2. I request that the State of New Hampshire pay my portion of the cost of court ordered mediation ($60 per hour - $300 set fee, divided between the parties, for up to 5 hours of mediation) because I am unable to pay the fee at this time and will be unable to at the time of mediation. I understand that I will be required to repay the State of New Hampshire for the services provided to me by the court-appointed mediator. I understand that if at any time prior to the final disposition of my case, my financial condition improves I must notify the court immediately. By submitting this request and the attached Financial Affidavit and completed Child Support Guidelines Worksheet, I acknowledge that my financial condition may be investigated, my employment and credit verified, and a report made to the court. Signature of Applicant Printed Name of Applicant Date ORDER Based on this request, the Financial Affidavit of Assets and Liabilities, and the completed Child Support Guidelines Worksheet the applicant is: Ineligible to have the State of NH pay for court ordered mediation from the mediation fund. Eligible to have the State of NH pay for court ordered mediation from the mediation fund and liable for repayment. The amount of repayment will be determined by the Office of Cost Containment. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge NHJB-2683-F (01/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com