NINTH JUDICIAL ADMINISTRATIVE DISTRICT OFFICE OF DISPUTE RESOLUTION MEDIATION REPORT IN THE MATTER OF _______________________________V. _____________________________________ In the ___________Court of _________County, Georgia. Case/File No. __________, Judge ______________ A mediation session in the above styled case was scheduled on ____________, 2012, at _____________am/pm. The session lasted ______________hours. PERSONS ATTENDING THE SESSION WERE: (PRINT ONLY) _____________________________(plaintiff) _____________________________(plaintiff) ____________________________________(defendant) ____________________________________(defendant) _____________________________(plaintiff attorney) ____________________________(defendant attorney) _____________________________(plaintiff attorney) ____________________________(defendant attorney) _____________________________(mediator) ____________________________________ (observer) The results of the mediation session are as follows: (please check appropriate boxes; DO NOT WRITE ANY COMMENTS ON THIS FORM ­ ATTACH A SEPARATE SHEET.) 1. The case was mediated and a full agreement reached. _______ original attached (unless court requires original, ie: magistrate court) _______ original attached, and final order to be drafted by ___________________(name and title) 2. The case was mediated and a partial agreement was reached. _______ original attached (unless court requires original, ie: magistrate court) _______ original attached with final order to be drafted by ___________________(name and title) 3. This case was mediated but no agreement was reached. 4. No show: (circle) plaintiff / defendant / both; _____________________________________(name(s)) 5. Compensation for mediation services: _______paid in full by both parties _______payment due from (circle) plaintiff / defendant / both in the amount of $__________________. _______Stipend from ADR fund _______Pro Bono case ALL PARTIES IN ATTENDANCE MUST SIGN THIS FORM. ______________________________ Plaintiff ______________________________ Defendant ______________________________ Mediator Print and Sign Name ___________________________ Plaintiff ___________________________ Defendant ___________________________ Title: ______________________ ____________________________ Attorney for Plaintiff ____________________________ Attorney for Defendant ____________________________ Title: ______________________ THIS FORM MUST BE RETURNED BY THE MEDIATOR TO THE 9TH JAD ODR, ALONG WITH ORIGINAL GUIDELINES, ORIGINAL AGREEMENT, IF APPROPRIATE, AND $15.00 ADMINISTRATIVE FEE, WITHIN 24 HOURS OF THE MEDIATION SESSION. American LegalNet, Inc. www.FormsWorkFlow.com