THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) New Hampshire Supreme Court Date Appeal Filed: APPELLATE MEDIATION PROGRAM PARTY INFORMATION FORM Each party in a case referred to mediation must complete this form and submit it to the ADR Program Coordinator by the date set forth in the Supreme Court order. A copy should also be sent to all other parties. Name of Party Filing Form: Filing Status of Party Filing Form (Check all that apply): Appellant Appellee Pro Se Other If filing party is represented by counsel: Name of Counsel: Address: Bar ID #: Telephone: Fax: Cross Appellant Cross Appellee If filing party is not represented by counsel: Name of Person Filing Form: Address: Telephone Number: Fax Number: Names and addresses of all other parties and counsel involved in this matter: Name of Party: Name of Counsel: Address of Party: Address of Counsel: If this case or a related case has been appealed to the supreme court previously, please provide case name and supreme court case number. Identify any factors that may affect the suitability of case for mediation, including, but not limited to the following factors: Presents an issue of interpretation of state or federal constitution Presents an issue of first impression Presents an issue of validity of state statute, ordinance or agency regulation Inconsistent with decisions of other trial courts NHJB-2615-SUP (11/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: APPELLATE MEDIATION PROGRAM ­ PARTY INFORMATION FORM History of settlement negotiations, if any (Including a listing of previous demands and offers): Description of monetary, physical injury, or any other damages upon which the claim is based: Out-of-pocket expenses upon which the claim is based: I hereby certify that, on or before the date below, copies of this form were served on all parties to the case. Date Party or Counsel Send completed form to: Appellate Mediation Program 45 Chenell Drive Suite 2 Concord, New Hampshire 03301 NHJB-2615-SUP (11/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com