COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : IC Form MSC7 (Rev. 9/01) Index No. NORTH CAROLINA INDUSTRIAL COMMISSION N.C. Industrial Commission Mediation Section 4342 Mail Service Center Raleigh, NC 27699-4342 -against- : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA : ________________________________, Plaintiff : REPORT OF EVALUATOR v. ________________________________, Defendant ________________________________ , Carrier Defendant(s) : : ...................................................... Evaluator________________________ telephone _________________________fax _______________________________ Address_________________________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK The undersigned evaluator reports the following results of a neutral evaluation conference in this case: TO Conference ___ was held. ___ was not held. If not held, the reasons were: _______________________________________ ___________________________.Number of sessions held: _____ Date conference was completed: ___________________ Names of parties, attorneys, insurance representatives or others who were absent: ________________________________ GREETINGS: ____________________________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court The parties reached:___ agreement on all issues. ___ an impasse. ___ agreement on the following issues: located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed ____________________________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the If this case was not settled, the parties estimate that the length of the hearing in this case will be _______. Issues settled to be disposed of by: ___ clincher ___ other agmt. ___ voluntary dismissal ___ removal from hearing Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to docket the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a The personof your failure to the agreement/clincher /dismissal to the Commission is _____________________________ result who will submit comply. __________________________________________, who will submit it by _________________________________ (date). Witness, Honorable Court in County, , one of the Justices of the day of , 20 Evaluator’s Fee PREPARATION FEE: $____________ EVALUATION FEE: Total time spent in Neutral Evaluation Conference: _______.___ hours $____________ (Attorney must sign above and type name below) OTHER FEE (Postponement fee, etc...., if any) $_______________ TOTAL FEE All fees to the evaluator have been paid except as follows: Party owing fee Amount owed Attorney(s) for $____________ Address of party ____________________________________________________________________________________________________ Office and P.O. Address I have mailed this report to the Commission within seven days of the conclusion of the neutral evaluation conference. This the ___ day of ________________, ______. ____________________________________________________ Evaluator Telephone No.: Federal Tax ID No. Facsimile No.: This report is to be returned to the Commission in all cases, whatever the neutral evaluation E-Mail Address: results. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com