THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AGREEMENT TO MEDIATE I understand and agree that: Mediation is a private and consensual process in which I will work to explore options for resolving the matter that brought me here today. Responsibility for resolution of the dispute rests with me and the other parties and I will be responsible for any agreements I may make during the mediation. I am in mediation voluntarily and in good faith. By consenting to this mediation, I affirm my willingness to speak honestly and disclose information important to bringing this matter to a fruitful outcome. The mediator is an impartial person whose role is to help us have a productive conversation about the matter that brought us here today and to help us decide how and on what terms we might resolve this matter. The mediator will not counsel, give advice about or make decisions regarding the outcome or resolution of this dispute. The mediator is not providing me with legal advice or counseling services. The mediator will hold confidential the written and oral communications that occur prior to, during or after the mediation, except as provided by NH law or Probate Division Administrative Order 11. I will not call or subpoena the mediator as a witness in, or request the mediator's records for, any court, legal or administrative proceeding arising from this mediation as provided in Probate Division Administrative Order 11. The mediator will destroy notes taken before or during the mediation. Any memorandum of understanding generated by the mediation shall be a record of the parties' mutually acceptable understanding of the issues discussed. The mediator gives no opinion regarding the legal implications of the Agreement to Mediate, the memorandum of understanding, any summaries of the parties' discussion or any resolution that is reached. Petitioner or Plaintiff Counsel for Petitioner or Plaintiff Date Date Petitioner or Plaintiff Counsel for Petitioner or Plaintiff Date Respondent or Defendant Counsel for Respondent or Defendant Date Respondent or Defendant Counsel for Respondent or Defendant Date Mediator Mediator American LegalNet, Inc. www.FormsWorkFlow.com NHJB-2179-FP (07/01/2011) Page 1 of 1