COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : IN THE ______________COURT FOR ________________________, TENNESSEE JUDICIAL SUBPOENA Plaintiff(s) -against_______________________________________ Plaintiff VS. : : NO. ____________________ ________________________________________ Defendant Defendant(s) : : ...................................................... MEDIATOR’S REPORT OF PRO BONO MEDIATION Mediation was THE STATE OF NEW YORK THE PEOPLE OFordered on _____________, 20___. Mediation was started on _____________, 20___. TO Mediation was actually completed on _____________, 20___. GREETINGS: in mediation: ____________ hours. Hours spent WE COMMAND YOU, number of mediator: ___________________________________ Name, address, phone and fax that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 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 _____________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to ________________________________________ ______________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Mediator’s Signature Date result of your failure to comply. ______________________________________________________________________________ Witness, Honorable one of the Justices Please send a copy of the original order to mediation and the original ,of this form to: of the Court in County, day of Programs Manager Pro Bono Mediation Administrative Office of the Courts 511 Union Street, Suite 600 Nashville, Tennessee 37219 , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com