STATE OF NORTH CAROLINA County Name Of Plaintiff File No. In The General Court Of Justice District Court Division Name Of Defendant VERSUS PETITION AND ORDER FOR RELIEF FROM OBLIGATION TO PAY ALL OR PART OF MEDIATOR'S FEE IN FAMILY FINANCIAL CASE G.S. 7A-38.4A; Rule 7.E of the Rules Implementing Settlement Procedures in Equitable Distribution and Other Family Financial Cases PETITION The undersigned party petitions the Court for relief from the obligation to pay all or a full share of the mediator's fee incurred in connection with the mediated settlement conference in the above case. Unpaid balance of my obligation Total value of my assets Total amount of my debts and liabilities I affirm to the Court that I cannot pay all or part of this obligation. Name And Address Of Party (type or print) Date Signature Of Party Telephone No. $ $ $ Plaintiff Defendant NOTE: The party requesting relief should give this Petition to the mediator at the conclusion of the settlement conference, and the mediator should attach the petition to the Report Of Mediator. The judge may require more detailed financial information. ORDER The above Petition For Relief from Obligation To Pay All Or Part Of The Mediator's Fee is: ALLOWED, and the moving party is relieved of the obligation to pay any of the mediator's fee. ALLOWED, and the moving party is ordered to pay this portion of the mediator's fee: $ Date Name (type or print) Signature . DENIED, and the moving party is ordered to pay the mediator's fee in full within thirty (30) days of the date of this Order. District Court Judge District Court Judge's Designee Original-Court File Copy-Mediator Copy-Petitioning Party AOC-CV-828, Rev. 10/14 � 2014 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com