United States Bankruptcy Court Northern District of Illinois Eastern Division Eastern Division In re _______________________________, Debtor , _______________________________, Plaintiff _______________________________, , Defendant ) ) ) ) ) ) ) ) ) ) ) ) ) Case No. _____________________________ Chapter _____________________________ _______________________________ ________________________ Judge Date (if applicable) Adv. Proc. No. _____________________________ The undersigned party or Parties ("Parties") hereby request that this court enter an order referring the following dispute to mediation pursuant to the Local Bankruptcy Rules: (brief description of the nature and status of the dispute) 1. Have the necessary Parties agreed upon mediation of this dispute? Yes No 2. If the Parties have agreed upon a mediator, state the name, address and phone number of the mediator agreed upon: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 3. If the Parties do not notify the clerk that they have agreed upon a mediator, the Parties understand and agree that, then within seven (7) days of the entry of an order of reference to mediation, the clerk will randomly assign a mediator from the list of mediators maintained by the clerk pursuant to Local Bankruptcy Rule 9060-5A. 4. By agreeing to enter into mediation with the intention of reaching a consensual settlement of their dispute, the Parties and their counsel agree to be bound by the Local Bankruptcy Rules governing mediation and to proceed in a good faith effort to resolve this dispute. Wherefore, the undersigned Parties and their counselrequest that the court enter an order referring this dispute to mediation and granting such other relief as is just and proper. Signed:_________________________________Print name: _______________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Date: American LegalNet, Inc. www.USCourtForms.com ______________________________ ___________________________ __________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________