STATE OF NORTH CAROLINA County Name Of Plaintiff(s) File No. In The General Court Of Justice Superior Court Division Name Of Defendant(s) VERSUS PETITION AND ORDER FOR RELIEF FROM OBLIGATION TO PAY MEDIATOR'S FEE G.S. 7A-38.1, 7A-38.4A; Rule 7.D of the Rules Implementing Statewide Mediation Settlement Conferences and Other Settlement Procedures in Superior Court Civil Actions PETITION The undersigned party petitions the Senior Resident Superior Court Judge for a finding of indigency and for relief from the obligation to pay a 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 am an indigent person who cannot pay this obligation. Name And Address Of Party (Type Or Print) Date Signature Of Party Telephone No. $ $ $ Plaintiff Defendant Third Party 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 to be relieved of the obligation to pay the mediator's fee is: ALLOWED, and the moving party is relieved of the obligation to pay any mediator's fee. ALLOWED, and the moving party is ordered to pay this portion of the mediation's fee: $ DENIED, and the moving party is ordered to pay the mediator's fee within thirty (30) days of the date of order. Date Name Of Senior Resident Superior Court Judge (Type Or Print) Signature Of Senior Resident Superior Court Judge . Original-Court Copy-Mediator Copy-Petitioning Party AOC-CV-814, Rev. 7/14 � 2014 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com