IN THE SUPERIOR COURT OF__________________ COUNTY, GEORGIA ALTERNATIVE DISPUTE RESOLUTION PROGRAM SOUTHERN JUDICIAL CIRCUIT VOUCHER FOR COMPENSATION OF ASSIGNED NEUTRAL ________________________________ PLAINTIFF CIVIL ACTION FILE NO. ___________________ ________________________________ DEFENDANT NEUTRAL'S CERTIFICATION I certify that a Alternative Dispute Resolution, ("ADR"), session was conducted with the parties named above on ____________________________________________________, with the following results: ___________ A full agreement ___________ No agreement ___________ Other Request is hereby made for compensation in the amount of $__________________ for ADR services rendered. (1) Time spent in mediation: (2) Time spent in preparation: (3) Expenses: (Attach detailed statement) ____________________________________________________ Neutral's Signature ____________________________________________________ Printed or Typed Name ____________________________________________________ P.O. Box or Street Address ____________________________________________________ City, State, and Zip Code American LegalNet, Inc. www.FormsWorkFlow.com AUTHORIZATION FOR PAYMENT Approved for payment in the amount of $______________ to the above-named Neutral. This _______ day of ________________________________ , 20_____. ___________________________________________ Tim C. Hendrick Administrator, Alternative Dispute Resolution Program Southern Judicial Circuit Post Office Box 2227 Moultrie, Georgia 31776-2227 Telephone: (229) 890-5624 County File Name Civil Action File No. American LegalNet, Inc. www.FormsWorkFlow.com http://southernjudicialcircuit.com/vouche3.htm 5/18/2009