THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: MEDIATOR STATEMENT- DIVORCE AND PARENTING1 Name of Payee Name of Mediator if different from Payee Address of Payee Vendor # TYPE OF BILLING for Mediation payable through the Family Mediation Fund: $300 Fee for Mediation (5 hours – Both parties Fund) $ Mediation fee for (name of party) reduced fee due to circumstances $ Mediation fee for (name of party) $ Proportionate Fee for mediation (5 hours –Party A- Fund) $ Proportionate Fee for mediation (5 hours – Party B- Fund) $ Sliding Scale fee, if any 2 ( hours per hour). * Applies of mediation services at $ after the initial 5 hours of mediation time. reduced fee due to circumstances $120 Failure to Appear Fee NOTE: Mediators must attach a copy of the order appointing them as mediator. Billing for Mediation Grant $300 Fee for Mediation (5 hours) $120 Failure to Appear Fee NOTE: Mediators must attach a copy of the order appointing them as mediator and Mediation Data Collection Form. I represent that the foregoing is a true and reasonable bill for services rendered. Date Signature of Mediator I hereby certify that I have examined the above statement and find the charge of $ to be reasonable. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge 1 This form should be used when one or both parties have been approved to have the mediation fees paid through the Family/Indigent Mediation Fund or through the Mediation Grant. 2 Any amount billed after the initial fixed fee amount of $300 for 5 hours may only be billed after agreement by the parties and, if a Fund case, after a motion requesting the additional payment, consistent with the sliding scale, is granted by the Court. For the Mediation Grant the maximum amount to be billed is $300. NHJB-2681-FS (03/29/2012) American LegalNet, Inc. www.FormsWorkFlow.com