STATE OF NORTH CAROLINA County Name Of Plaintiff(s) File No. In The General Court Of Justice Superior Court Division Name Of Defendant(s) Name And Address Of Mediator VERSUS REPORT OF MEDIATOR IN SUPERIOR COURT CIVIL ACTION G.S. 7A-38.1; Rule 6.B(4) of the Rules Implementing Statewide Mediated Settlement Conferences and Other Settlement Procedures in Superior Court Civil Actions Telephone No. Of Mediator Fax No. Of Mediator (If Applicable) 1. The undersigned mediator reports the following results of a mediation settlement conference either voluntarily conducted in this case: a. Conference was held. was not held. b. If held, date conference was completed: c. If not held, the reasons were: ordered or 2. If the case was reported settled prior to or during a recess of the conference, provide the name(s) of the person(s) who reported the case settled: 3. The parties reached an: 4. agreement on all issues. impasse. If the case was settled, then, as required by MSC Rule 6.B(4)(b), the mediator has advised the parties that MSC Rule 4.C requires that closing documents be filed with the court within 30 days of settlement (or 90 days if a State or political subdivision is involved) or before expiration of the mediation deadline, whichever is longer. The following closing document is to be filed: a. consent judgment. Name: Address: Telephone number: ( ) Email Address: Affiliation (e.g., party, attorney, insurance company representative, lienholder, or other) 5. Names of those who attended the conference: Name voluntary dismissal with prejudice. voluntary dismissal without prejudice. b. Name, address, email, and telephone number of party or attorney who is to file the closing document: Original-File Copy-Senior Resident Superior Court Judge or his/her designee (Over) Copy-Plaintiff Copy-Defendant AOC-CV-813, Rev. 7/14 � 2014 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com Name Affiliation (e.g., party, attorney, insurance company representative, lienholder, or other) MEDIATOR'S FEE Court-Appointed Mediator Party-Selected Mediator ADMINISTRATIVE FEE (MSC RULE 7.B or as privately agreed with party-selected mediator) MEDIATION FEE (MSC RULE 7.B: $150.00 per hour for time spent in conference for courtappointed mediator, billed in quarter hour segments, or privately set fee for party-selected mediator) Total Time Spent in Mediated Settlement Conference(s): selected mediator) $ 150.00 $ Hours Minutes $ $ $ $ $ $ POSTPONEMENT/CANCELLATION FEE (MSC RULE 7.E or as privately agreed with partyTOTAL FEE All fees of the mediator have been paid, except as follows: Name Of Party Owing Balance Address Of Party Amount Of Balance $ $ $ $ Name of any party filing Petition For Relief From Obligation To Pay Mediator's Fee: (Please attach Petition For Relief.) I have filed this report with the Court as required within ten (10) days after conclusion of the conference or within ten (10) days of being advised by a party that this case settled before the date scheduled for mediation or during a recess of the conference. Date Name Of Mediator (Type Or Print) Signature Of Mediator AOC-CV-813, Side Two, Rev. 7/14 � 2014 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com