THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AGREEMENT TO MEDIATE/REPORTING FORM 1. I understand that mediation is VOLUNTARY, and that I have chosen mediation as an alternative to litigation. 2. I understand that by VOLUNTEERING to mediate, I am doing so because I want to have my case settled prior to having a hearing with a judge. 3. I understand that I am not required to mediate, and that I may have my case heard by a judge. 4. I understand that I may choose, at any time, and for any reason, to end the mediation without penalty. Furthermore, I understand that if I choose to end the mediation I may still pursue my case in court. 5. I agree that I will enter into the mediation session(s) in good faith and that all mediation proposals will be made in good faith. 6. I understand that if I do reach agreement through the mediation process, the agreement is legally binding and becomes a court order which can be enforced by the court. 7. I agree that any settlement discussions are confidential and may not be used against either party in subsequent hearings. 8. I understand that the mediation process is strictly confidential, and that no part of the discussion with the mediator(s), except reports of child abuse/neglect or threats of violence to self or others, is ever reported outside the program. 9. I agree that I will not subpoena the mediator(s) to testify in any court proceedings connected with the mediation sessions(s) or other activities related to the Small Claims Mediation Program of the New Hampshire Circuit Court. Plaintiff Defendant Mediator Date MEDIATION REPORT Case Settled at Mediation The Mediation Lasted: Case Did Not Settle at Mediation Date: Signature of Mediator NHJB-2349-DOMA (07/01/2011) min. Mediator Name (please print) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com