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'S CONFIDENTIAL MEDIATION STATEMENT Each party in a case referred to mediation must complete this form and submit it to the ADR Program Coordinator. This form is confidential. Copies should not be provided to the other parties to the case. Because the information will be reviewed only by the mediator and the ADR Program Coordinator in attempting to resolve the case, parties are encouraged to be candid in their responses. Parties may attach copies of the relevant decisions, memoranda, or other pleadings that will assist the mediator in understanding the case and the party's position. The appellant is required to attach copies of the trial court's decision(s) being appealed. Supreme Court Case Number: Date Appeal Filed: Name of Case: Name of Party Filing Form: Name of Person Filing Form: Address: Bar ID # (if an attorney): Telephone: Fax: Please describe why past efforts to resolve this case have been unsuccessful. Please list the important factors affecting your chances for success on appeal. Please list your most important priorities/interests in resolving this case in order of importance. NHJB-2616-SUP (11/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: APPELLATE MEDIATION PROGRAM ­ PARTY CONFIDENTIAL MEDIATION STATEMENT Please describe possible and acceptable outcomes for this mediation session Other than winning the appeal, what would be the ideal resolution of this case? Lowest acceptable monetary settlement value: $ Highest acceptable monetary settlement value: $ Party Date Party or Counsel Send completed form to: Appellate Mediation Program 45 Chenell Drive, Suite 2 Concord, New Hampshire 03301 NHJB-2616-SUP (11/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com