UNITED STATES DISTRICT COURT Western District of Washington Plaintiff/Petitioner vs. Case Number: Request for Pro Bono Mediation Defendant/Respondent Plaintiff, or Plaintiff's counsel, contact information: Daytime Phone: Address: E-mail Address: Defendant, or Defendant's counsel, contact information: Daytime Phone: Address: E-mail Address: Provide a short description of nature of case: Trial Date (if set) Discovery Cutoff Date (if set) Dispositive Motions Deadline (if set) Deadline for Conducting Mediation ( if set) Anticipated Date and Place of Mediation (or other ADR procedure) Basis of request for neutral to serve without compensation: (Check the applicable boxes) One or Both/All Parties have appeared Pro Se in this action. One or Both/All Parties are represented by Pro Bono counsel who are providing services without compensation. One or Both/All Parties are "unable, or are unable without financial hardship, to pay the anticipated fee for the services of the CR 39.1 Mediator (or other neutral)" None of the Above Please explain basis for request Page 1of 2 American LegalNet, Inc. www.FormsWorkFlow.com Please list the names of five (5) Rule 39.1 Neutrals from the court's register who the parties agree may serve as a mediator or arbitrator (if arbitration is requested.) If no names are identified by the parties, the ADR Committee Co-Chair(s) will endeavor to identify a mediator who is available to serve in this matter. 1. 2. 3. 4. 5. Signature(s) of Plaintiff(s) Counsel or Plaintiff (if Pro Se) and Date Signature(s) of Defendant(s) Counsel or Plaintiff (if Pro Se) and Date The completed form may be submitted electronically by clicking the e-mail button on the upper right hand corner of the first page, or can also be mailed to the attention of Sharon Haas, USDC Clerk's Office, 700 Stewart St, Suite 2310, Seattle, WA 98101. A list of certified Neutrals (Mediators) may also be found on our web site under Court Services, Alternative Dispute Resolution, To Find a Certified 39.1 Neutral. - ADR Committee Use ONLY The following Certified Attorney Neutral has agreed to provide mediation services on a Pro Bono (without cost) basis. Please contact the individual named below within days to schedule a meeting. Name Address City State Zip Code Phone Number E-mail Page 2of 2 American LegalNet, Inc. www.FormsWorkFlow.com