STATE OF NORTH CAROLINA DISTRICT COURT DIVISION COUNTY OF DAVIDSON FILE NO. _______________ _________________________________ ) Plaintiff(s) ) ) vs ) ) ________________________________ ) Defendant(s) ) REPORT ON MEDIATED SETTLEMENT CONFERENCE The parties and their respective counsel appeared for a mediated settlem ent conference on ___________________________ , _______ , at _____________ . The mediator was ___________________________________________ . The following claims (e.g ., custody, child support, postseparation support, alimony, equitable distribution) were subject to mediation: ________________________________________________________________________ ___ . The results of the mediation were as follows: Impasse declared at ____________________________________________________ . Settlement reached and reduced to writing as the claim(s) for ________ _____________ _____________________________________________________________________ . Other: _______________________________________________________________ . Claims and/or issues not successfully mediated and remaining for determi nation by the court are as follows: _______________________________________________________________ ____ The fee for mediation, in the total amount of $ _______________, was paid as follows: $ _______________________ (Amount paid by Plaintiff.) $ _______________________ (Amount paid by Defendant.) $ _______________________ (Amount remaining to be paid by _____________ ___-, on following terms: _____________________________________________________ . This the ______ day of ___________________, ________. ___________________________________ _______________________ , Mediator American LegalNet, Inc. www.USCourtForms.com