STATE OF NORTH CAROLINA County Name Of Plaintiff(s) File No. In The General Court Of Justice Superior Court Division Name And Address Of Plaintiff's Attorney (Or Pro Se Plaintiff's Address) DESIGNATION OF MEDIATOR IN SUPERIOR COURT CIVIL ACTION Telephone No. FAX No. (if applicable) Plaintiff's Attorney's Email Address (Or Pro Se Plaintiff's Email Address) Name Of Defendant(s) VERSUS Name And Address Of Defendant's Attorney (Or Pro Se Defendant's Address) NOTICE: Plaintiff's attorney should check and fill out only one of the two Sections, sign below, and return to the Senior Resident Superior Court Judge within 21 days after the date of the Order for Mediated Settlement Conference and distribute copies as noted below G.S. 7A-38.1; Rule 2 of Mediated Settlement Conferences Trial Date Date Of Order Referring Matter To Mediation Telephone No. FAX No. (if applicable) Deadline For Completion Of Mediated Settlement Conference Tentative Trial Date Defendant's Attorney's Email Address (Or Pro Se Defendant's Email Address) SECTION 1 - NOTICE OF SELECTION OF CERTIFIED MEDIATOR BY AGREEMENT The above named case was referred to a mediated settlement conference. The parties have selected the mediator named below who has agreed to serve in this case and is certified pursuant to the Rules Of Mediated Settlement Conferences. Name And Address Of Certified Mediator Telephone No. FAX No. (if applicable) Mediator's Email Address The parties and the mediator have agreed upon the mediator's rate of compensation as follows: (specify all terms of the compensation agreement.) NOTE: As an aid to mediator selection, the NC Dispute Resolution Commission maintains a list of certified superior court mediators at www.ncdrc.org. Click on "List of Mediators" from the left-hand menu then click on "Mediated Settlement Conference Program." You may search for mediators by name or by judicial district. Once a mediator's name appears on your screen, click on it for a complete contact and availability listing. SECTION 2 - MOTION FOR COURT APPOINTMENT OF MEDIATOR The above named case was referred to a mediated settlement conference. The parties have been unable to agree upon the selection of a mediator and move the Senior Resident Superior Court Judge to appoint a certified mediator to conduct their conference. Date Name Of Attorney (Or Pro Se Party) Signature Of Attorney (Or Pro Se Party) Original-File Copy-Senior Resident Superior Court Judge or his/her designee Copy-Plaintiff Copy-Defendant Copy-Mediator AOC-CV-812, Rev. 3/13 © 2013 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com ORDER OF APPOINTMENT The parties having reported their failure to agree upon the selection of a mediator or the parties having failed to notify the Court of their selection or nomination of a mediator within twenty-one (21) days after this case was ordered to mediation, the Court appoints the following certified mediator to conduct the mediated settlement conference. Name And Address Of Certified Mediator Telephone No. FAX No. (if applicable) Mediator's Email Address NOTICE TO MEDIATOR: 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 mediated settlement conference shall be completed by the completion deadline set forth above, and the mediator shall report the results of the conference to the Court within ten (10) days after the conference is completed. Date Name Of Senior Resident Superior Court Judge (Type Or Print) Signature Of Senior Resident Superior Court Judge CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date a copy of the foregoing Designation of Mediator in the Superior Court Civil Action was served on the above-selected mediator and the parties at the addresses below by placing a copy of the same in the United States Mail, postage prepaid. (Please provide names and addresses for the mediator and parties served in the spaces below. Attach additional sheets if necessary.) Name And Address Of Mediator Name And Address Of Party Or Attorney Name And Address Of Party Or Attorney Name And Address Of Party Or Attorney Name And Address Of Party Or Attorney Name And Address Of Party Or Attorney Name And Address Of Party Or Attorney Name And Address Of Party Or Attorney Date Name Of Party (Type Or Print) Signature Of Party or Party's Attorney AOC-CV-812, Side Two, Rev. 3/13 © 2013 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com