COMMONWEALTH OF MASSACHUSETTS ________________,SS: HOUSING COURT DEPARTMENT _______________ DIVISION _________________________ PLAINTIFF(S) VS. ________________________ DEFENDANT(S) REFERRAL TO HOUSING SPECIALIST DEPARTMENT NOTICE You are not required, prior to trial to go before the Housing Specialist. You have the right to refuse referral to a Housing Specialist. However, the Housing Specialist Department can sometimes help a complainant and defendant arrive at an agreement satisfactory to both. Housing Specialists are Court personnel. Anything said to a Housing Specialist, and any agreement made before a Housing Specialist prior to trial is held in strict confidence, and is not admissible as evidence if a trial is held. AGREEMENT I have read the above notice and agree to referral to the Housing Specialist Department. Complainant __________________________ Date: ___________ Address ______________________________ City/State ___________________________ Telephone ____________________________ Defendan t________________________ Address ______________________________ City/State ___________________________ Form Rev 7/99 Telephone ____________________________ American LegalNet, Inc. www.USCourtForms.com