COURT-FUNDED MEDIATION INVOICE MEDIATOR PAYMENT INFORMATION Return ORIGINAL invoice to: Pepper Flenner WV Supreme Court 1900 Kanawha Blvd East Building 1, Room E-100 Charleston, WV 25305 Mediator: _______________________________________________________ Make check payable to: _____________________________________________ Address for remittance: _____________________________________________ ____________________________________________ Phone(home): _____________________________ Fax:_________________________ Phone (work):_________________________________ E-mail address:_____________________________________________________ Payee’s SS # or F.E.I.N. (Whichever applicable): ______________________________________ HOURS AND MILEAGE: (each party must file an approved financial affidavit to qualify) Number of hours worked ______ @ $45.00/hour = $_________ Total fees County where mediation occurred:______________________________________ Case # ____________________________ originating in County of ___________________________________ If you traveled outside of your home county to mediate, provide the following information for mileage reimbursement County traveled to: ____________________________________ Your home county: ____________________________________ Round trip miles traveled ______________ x $0.______ per mile = Add total fees + total mileage = $ _________ Total mileage $ _______ Total due Paid through Parent Education and Mediation Fund 1759 Sign here in blue ink: Date: For Administrative Office Use Only Approved by:________________________________________________________________ Date: SCA-FC-505 (12/07) _____________ American LegalNet, Inc. www.FormsWorkflow.com Mediator:_______________________________________ County:_____________________ Case # ______________________ Mediation Date: ____________ PARTIES CONTACT INFORMATION (addresses REQUIRED for payments to be rendered) (1) Name:______________________________________________ Address: Approved financial affidavit ______________________________________________________ ______________________________________________________ Daytime phone:____________________________ Evening phone: ___________________________ (2) Name:______________________________________________ Address: Approved financial affidavit ______________________________________________________ ______________________________________________________ Daytime phone:_____________________________ Evening phone: ___________________________ MEDIATION INFORMATION: Date(s) of session(s): ___________________________ County where session held:___________________________ Time spent in mediation: _________ hours _________ minutes Administrative time spent outside of mediation: _________ hours _________ minutes MEDIATION OUTCOME REPORT: Was an agreement reached during the mediation session? Was agreement reached before session began? These parties failed to attend: Mother Yes No Yes, full agreement Father Yes, partial agreement No Both Did anyone in addition to the two parties attend the mediation? Yes No If yes please list the following information regarding the additional person(s) in attendance: (a) Name: ________________________________________ Relationship to party: _______________________ (b) Name: ________________________________________ Relationship to party: ______________________ SCA–FC-505 (12/07) American LegalNet, Inc. www.FormsWorkflow.com