| Initiating Party (Person requesting mediation) |
Attorney/Representative (If any) |
| Name _______________________________ |
Name _______________________________ |
| Address_______________________________ |
Address_______________________________ |
| ______________________________________ |
_______________________________________ |
| Phone (H)_____________________________ |
Phone (O)_____________________________ |
Phone (W) _____________________________ |
Phone (F) _____________________________ |
| |
|
| Responding Party (Person on other side) |
Attorney/Representative (If any) |
| Name _______________________________ |
Name _______________________________ |
| Address_______________________________ |
Address_______________________________ |
| ______________________________________ |
______________________________________ |
| Phone (H)_____________________________ |
Phone (O)_____________________________ |
| Phone (W) _____________________________ |
Phone (F) _____________________________ |
| |
|
| Type of dispute: (check one or more) |
Amount in dispute: $___________ |
| _____ Neighborhood |
|
_____ Insurance |
| _____ Consumer |
|
_____ Business |
| _____ Landlord/Tenant |
|
_____ Employment |
| _____ Accident |
|
_____ Probate |
| _____ Other (describe)__________________________________________________________ |
Enclosed is my check or money order for $15 to DMS for a processing fee. I understand that as the initiating party I am also responsible for the $15 mediation fee, if the mediation takes place.
