NHJB-2769-SUP (02/12/2019) THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: New Hampshire Supreme Court APPELLATE MEDIATOR STATEMENT Name of Mediator: SS# or Federal Tax ID # of Payee: Date of Mediation Session: Appellate Mediation Report (NHJB-2629-SUP) filed with the Supreme Court? Yes No Evaluations provided to the parties and counsel at the conclusion of mediation? Yes No Total: $400.00 Date Signature of Mediator Approved for Payment Date ADR Office of Mediation & Arbitration To ensure prompt payment please send this form to: New Hampshire Judicial Branch Administrative Offices Attention: Appellate Mediation Program 1 Granite Place, Suite N400 Concord NH 03301 American LegalNet, Inc. www.FormsWorkFlow.com