IN THE DISTRICT COURT OF APPEAL FOR THE STATE OF FLORIDA FIFTH DISTRICT Appellant(s), v. Appellate Case No. 5D County Case No. Appellee(s) / DATE: MEDIATION QUESTIONNAIRE* This uestionnaire will be used to determine whether this case is appropriate for appellate mediation. Pursuant to Administrative Order AOSC11-1, each party is ordered to electronically file a completed uestionnaire with the Court within ten (10) days of the date of the Court222s acknowledgment of the notice of appeal and serve a copy on opposing counsel the Confidential Statement Regarding Appropriateness of Appellate Mediation is only to be e-filed with the CouConfidential Statement will not be viewable by the opposing counsel or the opposing party). mediation forms shall be e-filed FAILURE TO RETURN QUESTIONNAIRE AND CONFIDENTIAL STATEMENT MAY RESULT IN SANCTIONS *Download Mediation forms at: www.5dca.org Rev. 0/ American LegalNet, Inc. www.FormsWorkFlow.com Appellant(s) Attorney (Lead Counsel): (Name) (Address) (City/State/Zip) (Telephone) (Fax) (E-Mail) (Florida Bar No.) Appellee(s) Attorney (Lead Counsel): (Name) (Address) (City/State/Zip) (Telephone) (Fax) (E-Mail) (Florida Bar No.) NATURE OF THE CASE Business Tort Contract Employment Family matter (with children issues) Insurance Family matter (without children issues) Real Estate Personal injury/wrongful death Other (please describe) ISSUES ON APPEAL (To be completed by Appellants/Cross-Appellants only): Describe each expected issue on appeal as now known and the standard of review which will be applicable to each issue (completion of the questionnaire will not limit issues which may be raised in the briefs). MEDIATION Was the case mediated at the trial level? Yes No Has the case been mediated since entry of the order appealed? Yes No American LegalNet, Inc. www.FormsWorkFlow.com - NOTICE - You are hereby given an extension to file your directions to the clerk and court reporter, upon your receipt of this form. If appellate mediation is ordered in this case, you will be given an automatic extension of the deadlines for preparation of the transcript, preparation of the record and filing of briefs, said time to run from the date of the notification from the Court that mediation is ordered until 10 days after mediation has concluded. [Mediation session has concluded with either an impasse or full or partial settlement]. The Court will send an Order Declining Referral to Mediation if mediation is not ordered in this case. (It is the intention of the Court that the mediation process will not substantially slow down the appellate process. However, the above extensions will give the parties the opportunity to save the costs of the record and brief preparation, if mediation is successful. Accordingly, additional extensions of deadlines pending mediation will normally not be granted absent stipulation of the parties and court order). Date: Counsel: For: (Counsel222s Certificate of Service that complies with Florida Rule of Appellate Procedure 9.420(d)(1) must be attached to this Questionnaire) CERTIFICATE OF SERVICE American LegalNet, Inc. www.FormsWorkFlow.com