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.
MEDIATOR'S CERTIFICATE OF COMPLETION OF MEDIATION CONFERENCE 1. I hereby certify that, pursuant to an order by this court dated _______________ referring this matter to the bankruptcy mediation program, a mediation conference(s):
9 was held on (list date(s) of conference(s)):
__________________________ __________________________ ___________________________ ___________________________
9 was not held.
2. A settlement resolution of this matter:
9 was reached
9 was not reached.
3. [If a settlement was reached:] The party designated to prepare the stipulation and proposed consent order to the court is _______________________________________________
C:\publishing\CERTCOMP.WPD/Feb.1998
Mediator's Certificate of Completion Of Mediation Conference,Sample Form
(identify party by name). The stipulation and proposed consent order will be filed on or before
C:\publishing\CERTCOMP.WPD/Feb.1998
Mediator's Certificate of Completion Of Mediation Conference,Sample Form
_____________________ (date).
Dated: __________________________
______________________________ Mediator's Signature Mediator's Name:________________________ Address: ______________________________ ______________________________ Telephone: ______________________________
C:\publishing\CERTCOMP.WPD/Feb.1998
Mediator's Certificate of Completion Of Mediation Conference,Sample Form