IN THE SUPREME COURT OF TENNESSEE AT JACKSON , ET AL. v. , ET AL. {PLAINTIFF} {DEFENDANT} No. ___________________ REPORT OF THE MEDIATOR The Rule 31 Mediator states as follows: Mediation as required by Provisional Rule 37 was completed on ________________, 20____. The settlement status of this case is as follows: G Case settled before mediation G Case settled in part G G Case settled by mediation Case did not settle. The participation by the parties in this case was as follows: G Parties appeared and participated in the mediation. G Not all parties appeared and participated in the mediation. G Representatives of the following parties appeared and participated in the mediation: ________________________ ________________________ ________________________ G Representatives of the following parties did not appear or participate in the mediation: ________________________ ________________________ ________________________ G ________________________ ________________________ The Rule 31 Mediator requests that the costs of the mediation services be charged as court costs. Respectfully submitted, _________________________________________ _________________________________, Mediator Address:__________________________________ _________________________________________ _________________________________________ Telephone:________________________________ Please complete this form and send to: Clerk of the Appellate Courts Attn: Workers= Comp Mediation Supreme Court Building P.O. Box 909 Jackson, TN 38302-0909 American LegalNet, Inc. www.USCourtForms.com