Save State of New Jersey For Office Use Only Date Received: Date Entered: COMPLETION OF MEDIATION FORM For Mediation of Economic Aspects of Family Law Cases Directions: This form is to be completed by the mediator when mediation is concluded or the case is returned to court. CASE DOCKET NUMBER CASE NAME NAME OF MEDIATOR OUTCOME mediation held / full agreement on all issues mediation held / some issues still pending mediation held / no agreement no mediation held / parties settled case before mediation session no mediation held / party failed to attend DATE OF INITIAL MEDIATION SESSION DATE OF FINAL MEDIATION SESSION DATE CASE ASSIGNED TO MEDIATOR NUMBER OF MEDIATION SESSIONS NUMBER OF HOURS FOR PREPARATION NUMBER OF MEDIATION HOURS DID THE ATTORNEYS/PARTIES SUBMIT PROPER CASE SUMMARIES? WERE THE ATTORNEYS/PARTIES PREPARED FOR THE MEDIATION SESSIONS? DID THE PARTIES PARTICIPATE IN THE MEDIATION SESSIONS? yes no yes no BY FAX: yes 609-984-0067 no PLEASE RETURN TO: Family Practice Division Revised Effective 09/01/2009, CN: 10491 (Rule Appendix XIX) American LegalNet, Inc. www.FormsWorkFlow.com