UNITED STATES DISTRICT COURT Case No.: FOR THE MIDDLE DISTRICT OF NORTH CAROLINA DIVISIONName of Plaintiff(s):REPORTOFMEDIATORVERSUSName of Defendant(s):Name and Address of Mediator:Telephone No.: The undersigned mediator reports the following results of a mediated settlement conference ordered in this case: Conference [ ] was held.[ ] was not held.If not held, the reasons were: . Number of conferences held: Date conference was completed: Place where conference was held: . Number of participants present: Number of observers: . List name of parties, attorneys, insurance representatives, or other who were present: SEE BACK OF FORM . The parties reached an: [ ] agreement on all issues.[ ] agreement on some issues.[ ] impasse. If the case was not settled, estimated length of trial (number of days) . If there was partial agreement, list issues settled: . Any agreement reached will conclude the lawsuit as follows:[ ] by consent judgment.[ ] by voluntary dismissal(s). If the case was settled, the documents to be filed, and the persons who are to file them are as follows: . [ ] Consent Judgment [ ] Voluntary Dismissal With Prejudice [ ] Voluntary Dismissal Without PrejudiceDate:Filed By: Please return completed report to: Greensboro, NC American LegalNet, Inc. www.FormsWorkFlow.com MEDIATOR 221S FEEFor Information purpose, please report the following:Total Travel Time: Hours MinutesTotal Mediation Time: Hours Minutes TOTAL>$All fees of the mediator have been paid except as follows:Name of Party Owing BalanceAddress of PartyAmount of Balance$$$PLAINTIFF(S): DEFENDANT(S): PLAINTIFF(S) COUNSEL: DEFENDANT(S) COUNSEL: I have mailed this report within seven (7) days after conclusion of conference to the Office of theClerk.Date:Signature of Mediator:MDNC-Mediator Report Revised 12/01 American LegalNet, Inc. www.FormsWorkFlow.com