Sample Form _____ UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY In re: Case No. Chapter Debtor. Use adversary caption if applicable. Plaintiff, Adversary No. v. Defendant. MEDIATOR’S CERTIFICATE OF COMPLETION OF MEDIATION CONFERENCE 1. I hereby certify that, pursuant to an order by this court dated _______________ referring this matter to the bankruptcy mediation program, a mediation conference(s): 9 was held on (list date(s) of conference(s)): __________________________ ___________________________ __________________________ ___________________________ 9 was not held. 2. A settlement resolution of this matter: 9 was reached 9 was not reached. 3. [If a settlement was reached:] The party designated to prepare the stipulation and proposed consent order to the court is _______________________________________________ C:\publishing\CERTCOMP.WPD/Feb.1998 Mediator’s Certificate of Completion Of Mediation Conference,Sample Form American LegalNet, Inc. www.USCourtForms.com (identify party by name). The stipulation and proposed consent order will be filed on or before C:\publishing\CERTCOMP.WPD/Feb.1998 Mediator’s Certificate of Completion Of Mediation Conference,Sample Form American LegalNet, Inc. www.USCourtForms.com _____________________ (date). Dated: __________________________ ______________________________ Mediator’s Signature Mediator’s Name:________________________ Address: ______________________________ ______________________________ Telephone: ______________________________ C:\publishing\CERTCOMP.WPD/Feb.1998 Mediator’s Certificate of Completion Of Mediation Conference,Sample Form American LegalNet, Inc. www.USCourtForms.com