DISPUTE RESOLUTION COMMISSION COMPLAINT STATE OF NORTH CAROLINA INSTRUCTIONS: Please type or print and mail along with any attachments to the N.C. Dispute Resolution Commission, P.O.Box 2448, Raleigh, NC 27602. Name And Address Of Complainant Telephone No. (Work Or Cell) Telephone No. (Home) 1. Name of the mediator, mediation trainer or mediation training program that is the subject of your complaint. (If your complaint is against a trainer, indicate the training program with which he/she is affiliated): 2. If your complaint concerns a mediator, identify the dispute or court case which the mediator was selected or appointed to mediate and from which your complaint arose. (If filed in court, please provide the case name and number assigned to your litigation by the Clerk. If the dispute in which you are or were involved has not been filed as a court case or assigned a number by the Clerk, list the principal parties involved:) 3. If a mediation conference was held, give the date(s) on which it was conducted and the location of the conference: 4. If your complaint involves a mediation trainer or training program, indicate the date(s) on which you attended training and the location where the training was held: 5. In the space below, please describe your complaint against the mediator, mediation trainer or training program named above and indicate all facts upon which your complaint is based. (If necessary, add additional pages.): AOC-DRC-05, Rev. 10/08 © 2008 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkflow.com Description of Complaint (continued from side one). 6. Provide below names of all individuals who have knowledge of your above complaint and indicate how they may be contacted. (Add additional pages if necessary.): Name And Address Of Individual 1 Name And Address Of Individual 2 Daytime Telephone No. Daytime Telephone No. 7. Please attach to this completed form copies of any correspondence or other documents which support your complaint. I have furnished the above information to allow the Dispute Resolution Commission to investigate my complaint and I agree to cooperate with the Commission in its investigation, including furnishing any evidence in my possession relating to this complaint and to my mediation or my mediation training. I further authorize the Commission to contact any individuals in the course of its investigation that were present for this mediation or that have information about the mediation, including my own attorney or opposing counsel. I further authorize those contacted to respond to the Commission's investigation by providing information and documents, including information and documents that might otherwise be confidential or subject to attorney-client privilege. I further agree that if a hearing is held in this matter that I will appear at the hearing or otherwise give evidence in support of my complaint. I understand that a copy of this complaint and any other information provided to the Commission may be shared with the mediator, mediation training program, or mediation trainer that is subject of this complaint. It may also be shared with witnesses listed above and with others identified during the course of the Commission's investigation. Date SWORN/AFFIRMED SUBSCRIBED TO BEFORE ME Date Signature Title Of Person Authorized To Administer Oaths Signature Of Applicant Name Of Applicant (Type Or Print) Date Commission Expires Notary County Where Notarized SEAL AOC-DRC-05, Side Two, Rev. 10/08 © 2008 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com