STATE OF NORTH CAROLINA County Name And Address Of Party Requesting Prelitigation Mediation Of Farm Dispute File No. APPOINTMENT OF MEDIATOR IN PRELITIGATION FARM NUISANCE DISPUTE NOTE TO PARTIES: The party requesting mediation should check and fill out only one of the three Sections, sign below, and return to the Clerk of Court. G.S. 7A-38.3 Telephone No. Email SECTION 1 - NOTICE OF SELECTION OF CERTIFIED MEDIATOR BY AGREEMENT The parties have selected the certified superior court mediator named below who has agreed to mediate their dispute. The mediator is certiifed pursuant to the Rules of Mediated Settlement Conferences. Name And Address Of Certified Mediator Telephone No. The parties and the mediator have agreed upon the mediator's rate of compensation as follows: (specify all terms of the compensation agreement) SECTION 2 - MOTION FOR COURT APPOINTMENT OF MEDIATOR A request for prelitigation mediation of a farm nuisance dispute has been filed with the Clerk. The parties have been unable to agree on a mediator to conduct their prelitigation mediation. Pursuant to G.S. 7A-38.3(d), the parties move the Senior Resident Superior Court Judge to appoint a certified superior court mediator to conduct their mediation. SIGNATURE Date Name Of Party Who Requested Mediation Signature Of Party Who Requested Mediation ORDER OF APPOINTMENT 1. The selection of the certified mediator named in Section 1 is acknowledged by the Clerk and the mediator is authorized to conduct the settlement conference. The mediator shall be responsible for reserving a place and making arrangements for the conference and giving timely notice to all attorneys and unrepresented parties of the time and location of the conference. The mediation shall be completed within sixty (60) days of the date of this Order of Appointment, and the mediator shall report the results of the conference to the Court within seven (7) days after the conference is completed. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court 2. The parties having reported their failure to agree upon the selection of a mediator, the Court appoints the following certified mediator to conduct the mediated settlement conference. Name And Address Of Certified Mediator Telephone No. The mediator shall be responsible for reserving a place and making arrangements for the conference and giving timely notice to all attorneys and unrepresented parties of the time and location of the conference. The mediation shall be completed within sixty (60) days of the date of this Order of Appointment, and the mediator shall report the results of the conference to the Court with seven (7) days after the conference is completed. Date Name Of Senior Resident Superior Court Judge (Type Or Print) Signature Of Senior Resident Superior Court Judge AOC-CV-821, Rev. 2/12 © 2012 Administrative Office of the Courts Original-File Copy-Parties Named in Request for Prelitigation Farm Mediation Copy-Mediator American LegalNet, Inc. www.FormsWorkFlow.com