Free [PFP#592105975] - Texas

BTXN 002 (rev. 2/99)

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS
ALTERNATIVE DISPUTE RESOLUTION SUMMARY

1. 2. 3. 4. 5.

Bankruptcy Case No.: ____________________________________________________ Date session(s) held: _____________________________________________________ Duration (i.e., half day, two days): __________________________________________ Your total fee? $ ________________________________________________________ Outcome of ADR (select one): " Parties did not use my services " Settled as a result of ADR " Settled in part as a result of ADR " Parties were unable to reach settlement

6.
Provider

Please list all persons in attendance (including party association):

7.

Please provide the names, addresses, and telephone numbers of counsel on the reverse of this form. Provider Information:
Address

8.
Signature

Date

City, State ZIP

Phone

Suite

Provider must file completed form in duplicate with the Bankruptcy Clerk.

Please provide the names, addresses, and telephone numbers of counsel in the space provided below.

Name

Name

Firm Name

Firm Name

Address

Address

City, State ZIP

City, State ZIP

Telephone

Telephone

Name

Name

Firm Name

Firm Name

Address

Address

City, State ZIP

City, State ZIP

Telephone

Telephone

Name

Name

Firm Name

Firm Name

Address

Address

City, State ZIP

City, State ZIP

Telephone

Telephone

Name

Name

Firm Name

Firm Name

Address

Address

City, State ZIP

City, State ZIP

Telephone

Telephone