MEDIATOR CLAIM FOR REIMBURSEMENT FROM DIVORCING PARENT EDUCATION AND MEDIATION FUND (T.C.A. ' 36-6-413) FOR REDUCED FEE MEDIATION INSTRUCTIONS: Type and submit in duplicate to the clerk of the court. Please complete the form in full or it will be returned. Both copies must be signed by the mediator and the judge. The clerk shall retain one copy for the court files and shall forward the original to the Administrative Office of the Courts, Programs Manager, Divorcing Parent Education and Mediation Fund, 511 Union St., Suite 600, Nashville, TN 37219. STATE OF TENNESSEE COUNTY OF: ________________________ COURT: _______________________ PART: _______ DOCKET NO.: ____________ NAME OF MOTHER: ________________________________ Date of referral to mediation: ____________________________ In-session rate: Out-of-session rate: Mother $___________/hr. Mother $___________/hr. NAME OF FATHER:________________________________ Date mediation completed: ___________________________ Father $___________/hr. Father $___________/hr. to be reimbursed $________/hr. (= $50/hour - Mother=s rate - Father=s rate) to be reimbursed $________/hr. (= $40/hour - Mother=s rate - Father=s rate) ACTIVITY On the back of this form, itemize in-session and out-of-session hours spent working on this mediation. Attach a copy of the court order of appointment to the mediation. Totals: I certify that the foregoing represents an accurate, complete statement of time in connection with mediation in the above action or proceedings. _______________________________________________________ Signature of Mediator Date Soc. Sec. No.: __ __ __ - __ __ - __ __ __ __ (A) In-session hours (tenths) hrs. (B) Out-of-session hours (tenths) hrs. $ (C) Necessary Expenses Enter FULL Name, Address, and Phone Number Mediator: ____________________________________________ Address: _____________________________________________ _____________________________________________________ City: _______________________ State: ______ Zip: _________ Phone: ( __ __ __ ) __ __ __ - __ __ __ __ TO BE COMPLETED BY JUDGE (A) ________ total approved in-session time @ $_________/hour .................... $_________________________ (B) ________ total approved out-of-session time @ $_________/hour .............. $_________________________ (C) ________ total approved necessary expenses ............................................... $_________________________ Totals............................................. $_________________________ Subject to the provisions of T.C.A. ' 36-6-413 and Tennessee Supreme Court Rule 38, this Court finds this to be reasonable compensation for work done in the above case. This, the ______ day of ______________, 20______. _________________________________________________________ Signature of Judge TO BE COMPLETED BY THE ADMINISTRATIVE OFFICE OF THE COURTS Total authorized payment ............................................................ $______________________ Mediator Claim Form 9/05 1 of 2 American LegalNet, Inc. www.USCourtForms.com DATE ACTIVITY Itemize in-session hours, out-of-session hours, and necessary expenses incurred working on this case. (A) In-Session Hours (tenths) (B) Out-of-Session Hours (tenths) (C) Necessary Expenses Totals: hrs. hrs. $ Mediator Claim Form 9/05 2 of 2 American LegalNet, Inc. www.USCourtForms.com