For Office Use Only State of New Jersey MEDIATION CASE INFORMATION FORM Date Received: Date Entered: 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 CASE ASSIGNED TO MEDIATOR DATE OF INITIAL MEDIATION SESSION DATE OF FINAL MEDIATION SESSION 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 PLEASE RETURN TO: FAMILY DIVISION Revised 02/01/2007, CN 10491-English yes no yes no OR FAX TO: page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com