APPENDIX H (L.R. 7.05) COURT OF COMMON PLEAS BUTLER COUNTY, OHIO : Case No._________________________ : : : ORDER TO PAY MEDIATOR : : : Plaintiff(s), vs. Defendant(s). , attorney, being a duly appointed mediator in the within action, hereby applies to the court pursuant to Rule 7.05 of the Rules of Court, General Division, Common Pleas Court, Butler County, Ohio, for payment of mediator's fee in the amount of five hundred dollars ($500). This case did/did not settle through mediation held on _________________. _____________________________ Mediator _____________________________ Address ENTRY Upon application of the mediator in the above captioned action, the court finds the above application to be proper in all respects and orders a fee of five hundred dollars ($500) to be paid to the applicant pursuant to Rule 7.05 of the Rules of Court, General Division, Common Pleas Court, Butler County, Ohio. It is further ordered that the Auditor issue a warrant payable to the appointed mediator in the amount of five hundred dollars ($500). Said amount to be paid from Account 13284160.531000 of this court's budget. _____________________________ Judge Common Pleas Court INSTRUCTIONS TO THE CLERK: This case did not settle, the five hundred dollar ($500) mediator fee shall be taxed as costs of this action. The Clerk shall reimburse the General Division Account 13284160420000, with the refunded costs, pursuant to Local Rule 7.05(C). SO ORDERED. ____________________________________ Judge Common Pleas Court Appendix Page 10 American LegalNet, Inc. www.FormsWorkFlow.com