IN THE _________________ COURT OF _______________________, TENNESSEE __________________________________________ Plaintiff/Petitioner vs. __________________________________________ Defendant/Respondent ORDER TO MEDIATE DESIGNATING A MEDIATOR The Court, having determined that referral to mediation is appropriate in this case either on the Court's own motion or on the motion of one of the parties, it is hereby ORDERED that in accordance with Rule 31 of the Rules of the Tennessee Supreme Court ________________________________________ is hereby designated to conduct mediation in this case; and it is further ORDERED that mediation will be conducted upon the following issue(s): ______________________________________________________________________________ _____________________________________________________________________________; and it is further ORDERED that the mediator will file a report pursuant to sections 8 and 12(j) of Rule 31 with the Clerk of the __________ Court of __________ County, Tennessee; and it is further ORDERED that the attorneys will file an Order reflecting any agreement reached as a result of a successful mediation within __________________ (____) hours of the mediation; and it is further ORDERED that the fees of the mediator will be paid by the parties at the time of mediation, or if agreement concerning payment is not reached at that time, the fees of the mediator may be taxed as court costs. ENTERED this _____ day of ______________, 20___. NO. _________________ ____________________________________ Chancery or Circuit Court Judge *** Certificate of Services follows *** American LegalNet, Inc. www.USCourtForms.com CERTIFICATE OF SERVICES I hereby certify the foregoing has been delivered by personal delivery of the U.S. Mail to its destination upon all the parties to this action or their attorney of record as follows: _________________________________ _________________________________ _________________________________ _____________________________ _____________________________ _____________________________ This ______day of _____________, 20______. _______________________________________________ Name and title _______________________________________________ Signature American LegalNet, Inc. www.USCourtForms.com