NINTH JUDICIAL CIRCUIT OF ILLINOIS NOTIFICATION INFORMATION SHEET FOR COURT ORDERED MEDIATION PROGRAM To each Mediator participating in the Ninth Judicial Circuit Mediation Program: Please fill out this form upon your appointment as mediator. This information is necessary to avoid appointing the same mediators to multiple pro bono cases. Your cooperation is greatly appreciated. Please mail or fax this completed form to: Office of the Chief Judge 130 South Lafayette, Suite 30 Macomb, Illinois 61455 Phone 309-837-9278 Fax 309-833-3547 1. COUNTY FROM WHICH CASE WAS REFERRED: [ ] Fulton [ ] Hancock [ ] Henderson [ ] Knox [ ] McDonough [ ] Warren 2. Case No. ____________________ 3. Date Appointed by Court:_________________________________________ 4. Cost of mediation will be: [ ] Regular fee [ ] Reduced fee [ ] Pro bono Dated: Mediator Name:________________________________________________ Address:______________________________________________________ Phone: Fax: 07/07 American LegalNet, Inc. www.FormsWorkFlow.com