UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov VERIFICATION OF QUALIFICATION TO ACT AS MEDIATOR In accordance with Local Rule 9019-2 of the U.S. Bankruptcy Court for the Southern District of Florida, I verify that I qualify for and agree to service as a mediator under this rule as follows: 1. I am (check one) [ ] an active member of the Florida Bar and am qualified to practice in this court and I have been admitted to practice in a state or federal court for at least the past 5 years; or [ ] a retired federal or state judge. 2. I have: (check one or both) [ ] completed a minimum of 40 hours in a circuit court mediation training program certified by the Florida Supreme Court; [ ] have been certified by the Florida Supreme Court as a circuit court mediator. 3. I agree to accept at least 2 mediation assignments per year in cases where at least one party lacks the ability to compensate the mediator, in which case I understand that my mediator's fees will be reduced accordingly or I will serve as mediator pro bono if no litigant is able to contribute compensation. 4. I have taken the oath or affirmation prescribed by 28 U.S.C. §453 and have attached proof thereof to this Verification. 5. I agree to accept the current compensation rate established by the U.S. District Court for the Southern District of Florida and adopted by this court and, where applicable, as provided by Rules 9019-2(A)(2)(d) and (A)(6). 6. I am familiar with and will comply with all notice and report requirements contained in Rule 9019-2. 7. I will disclose to the court any bias or prejudice which may disqualify me as a mediator under Rule 9019-2(B)(2). 8. I will accept referrals for cases in the following divisions: [ ] Miami [ ] Ft. Lauderdale [ ] West Palm Beach I certify under penalty of perjury that all the information on this form is true. Signature Date: Name: (Printed or typed) Florida Bar No.(if applicable) Address: Attach proof of item #4 Phone: THIS FORM MUST BE FILED WITH THE CLERK'S OFFICE. YOU MAY ATTACH A ONE PAGE RESUME TO THIS VERIFICATION. LF-50 (rev. 06/02/08) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA MEDIATOR'S OATH Each mediator of the United States Bankruptcy Court shall take the following oath or affirmation before performing the duties of his office: "I, do solemnly swear that I will administer justice without respect to persons, and do equal rights to the poor and to the rich, and that I will faithfully and impartially discharge and perform all the duties incumbent upon me as a mediator for the United States Bankruptcy Court, Southern District of Florida, under the Constitution and laws of the United States, so help me God". By: (Signature) (Print Name) SWORN TO AND SUBSCRIBED before me on . by . NOTARY PUBLIC, State of Florida at Large My Commission Expires: LF-50 (rev. 06/02/08) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com