Supreme Court of Appeals of West Virginia Independent Contractor AGREEMENT for MEDIATORS For office use only: WVFIMS Vendor # __________________________ I_____________________________________, hereinafter MEDIATOR, agree to perform mediation services for eligible families at a rate of forty-five dollars ($45.00) per hour for mediation where both parties meet the “fee waiver” guidelines of the Supreme Court of Appeals of West Virginia, hereinafter COURT. Eligibility shall be determined by the Circuit Clerk or Family Court Judge ordering the parties to mediation according to the “West Virginia Supreme Court of Appeals Financial Guidelines for Determining Eligibility for Waiver of Fees, Costs or Security in Civil Cases.” I may also request reimbursement for my reasonable travel expenses in accordance with the travel regulations of the Court. The term of service begins on July 1, 2003 and can be terminated by either party to this agreement. This agreement in no way creates an employer-employee relationship between MEDIATOR and COURT. MEDIATOR will act only as an independent contractor under this agreement. Approved by: West Virginia Supreme Court of Appeals Mediator /Vendor ________________________________________ Administrative Director __________________________________________ Vendor’s signature ________________________________________ Date __________________________________________ Social Security or FEIN # __________________________________________ Date __________________________________________ Print Vendor’s Name __________________________________________ __________________________________________ Vendor’s Mailing Address __________________________________________ Vendor’s Phone and Fax Numbers __________________________________________ Vendor’s E-mail address SCA-FC-504 (11-06) American LegalNet, Inc. www.FormsWorkflow.com