UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE SAMPLE v. Civil No. _______________ CONSENT TO MEDIATION The parties in the above-captioned matter agree that ___________________________ is an acceptable mediator. It is further agreed that both counsel and parties will participate in good faith and shall cooperate with the mediator. The parties have agreed to pay (directly to mediator) the $____ hourly rate as follows: _______________________________________________________ _______________________________________________________ _______________________________________________________ _____________________________ Counsel for Plaintiff Date ______________________________ Plaintiff Date _____________________________ Counsel for Defendant Date ______________________________ Defendant Date (Form to be sent directly to Mediator–DO NOT FILE WITH COURT) American LegalNet, Inc. www.USCourtForms.com