NHJB-2614-SUP (08/06/2018) THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: APPELLATE MEDIATION AGREEMENT FORM Name of Party Filing Form: Counsel for Party Filing Form: List of other parties or counsel: Phone numbers and/or e-mail addresses: Phone: E-mail: Phone: E-mail: Phone: E-mail: Phone: E-mail: Phone: E-mail: Phone: E-mail: The agreement of all parties to participate in appellate mediation is necessary for the case to be referred to the office of mediation and arbitration for appellate mediation. I have contacted each party or their counsel to determine whether they agree to mediation. Yes OR No: If the answer is YES, do all parties or their counsel agree to mediation? Yes OR No: American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: APPELLATE MEDIATION AGREEMENT FORM NHJB-2614-SUP (08/06/2018) ANSWER YES TO ONE OF THE FOLLOWING (BUT NOT BOTH) I am filing this form electronically. I certify that a copy of this form is being or has been served on all other parties or their counsel, in accordance with the rules of the Supreme Court, as follows: I am serving registered e-filers through the court222s electronic filing system; I am serving or have served all other parties by mailing or hand-delivering a copy to them. OR I am not filing this form electronically. I certify that a copy of this form is being or has been served on all other parties or their counsel, in accordance with the rules of the Supreme Court, as follows: I am serving or have served all other parties by mailing or hand-delivering a copy to them. /s/ Name of Filer Signature of Filer Date Law Firm, if applicable Bar ID # of attorney Telephone Address E-mail City State Zip code File this form electronically or return form to: Office of the Clerk New Hampshire Supreme Court 1 Charles Doe Drive Concord, New Hampshire 03301 American LegalNet, Inc. www.FormsWorkFlow.com