FORM 6 Plaintiff (s) vs. Defendant(s) : IN THE COURT OF COMMON PLEAS : OF LACKAWANNA COUNTY : : : : : : NO. ____CIV_____ CONFIDENTIAL MEDIATION MEMORANDUM 1. Identification of Counsel: a. Attorney for Plaintiff: b. Attorney for Defendant: 2. Lacka. Co. R.C.P. 238 Confirmation of Settlement Offer and Response: a. Date and amount of settlement offer(s): b. Date and substance of response to settlement offer(s): 3. Insurance information: a. Identity of insurance carrier: b. Identity of insurance adjuster: c. Policy limits: d. Coverage issues (if any): 4. Statement of Facts and Legal Issues: 5. Injuries: 6. Calculation of Special Damages: a. Wage loss (if any): b. Medical bills (if any): c. Other (explain): American LegalNet, Inc. www.FormsWorkFlow.com 7. Liens (if a lien has been asserted against all or part of any potential settlement, indicate the amount and entity making the claim, i.e. Worker's Compensation carrier, Department of Public Welfare, Health Insurance carrier, etc.): 8. Identification of Expert Witnesses: a. For Plaintiff: b. For Defendant: 9. Estimated Number of Trial Days: 10. Any additional issues which should be considered to facilitate the settlement of this matter: American LegalNet, Inc. www.FormsWorkFlow.com