Free accept by mediator - New Jersey

Sample Form

UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY In re: Case No. Chapter Debtor. Use adversary caption if applicable. Plaintiff, v. Defendant. Adversary No.

ACCEPTANCE BY MEDIATOR I hereby agree to act as mediator in this matter under the terms and guidelines set forth in the consent order for referral to mediation. To my knowledge, I do not have a conflict or adverse interest to the estate or to any party to the bankruptcy case. I am a disinterested person within the meaning of 11 U.S.C. § 101(14).

_________________________________ Mediator Date:_____________________

C:\publishing\ACCEPT.WPD/Feb.1998

Acceptance of Mediator - Sample Form