Free Mediation Eligibility Form and Confidential Mediation Statement - Rhode Island

RHODE ISLAND SUPREME COURT APPELLATE MEDIATION PROGRAM
MEDIATION ELIGIBILITY FORM AND CONFIDENTIAL MEDIATION STATEMENT

INSTRUCTIONS This is a two-part, double-sided form. Part I determines the eligibility and appropriateness of your case for mediation. Part II applies to eligible cases only and contains confidential information about your case in order to assist the mediator in a resolution as well as an authorization to mediate. 1. Pursuant to Provisional Rule A as amended, all parties must complete this form and submit it to the Supreme Court Appellate Mediation Program within twenty (20) days of filing a Notice of Appeal. All parties must send an original and two copies of Part I to the Appellate Mediation Program and one copy to all opposing counsel. 2. If your case is not eligible for mediation pursuant to Provisional Rule A as amended, you need not complete Part II of this form. Send the original and two copies only of Part I to the Appellate Mediation Program and one copy to opposing counsel. 3. If your case is eligible for mediation, you are required to complete Part II of this form as well. While Part I of the attached form is to be shared with opposing counsel, Part II provides parties an opportunity to inform only the mediator of additional information that could lead to resolution. Candor and honesty are strongly encouraged. a. Complete fully Part II (the confidential mediation statement) inclusive of the confidentiality and negotiation authorization section. Attach copies of the relevant orders, memoranda, and opinions from which this appeal has been taken. If you are the appellant(s) or cross-appellant(s), you are required to attach copies of the trial court's written decision(s) or order(s). b. Send the original and two copies of the form to the Appellate Mediation Program at the address indicated. Retain a copy for yourself to bring to the mediation session when assigned. Do NOT send a copy of Part II (the confidential mediation statement) to opposing counsel. 4. If after submission of your statements, your case is deemed eligible and appropriate for mediation, the Appellate Mediation Program will send notice of the scheduled session to all parties. To adequately prepare for mediation, counsel should become fully aware of his/her client's interests, goals, and needs and acquire appropriate authority to participate in the mediation conference and the potential settlement. Counsel should further educate his/her client regarding the mediation process and its possible outcomes. 5. If after submission of your statements, it is determined that your case is not eligible or appropriate for mediation, the parties will be sent notification by the Appellate Mediation Program that the case has not been selected and the case shall proceed in accordance with the Supreme Court Rules of Appellate Procedure.
AMP-3/Rev. Dec. 2004

RHODE ISLAND SUPREME COURT APPELLATE MEDIATION PROGRAM PART I: MEDIATION ELIGIBILITY FORM
NAME OF CASE NAME OF PARTY OR PARTIES APPEALING NAME OF PERSON FILING THIS STATEMENT ADDRESS RI BAR No. TEL. TRIAL COURT CASE NUMBER DATE APPEAL FILED FAX

FILING STATUS (Check all that apply) APPELLANT CROSS-APPELLANT CASE TYPE

PRO SE APPELLEE

CROSS-APPELLEE

OTHER:__________________

ALL CASES ARE ELIGIBLE EXCEPT IF THE BASIS OF THIS APPEAL INVOLVES ANY OF THE FOLLOWING: (Please check all that apply. This section determines whether your case is eligible and whether you must complete Part II*) Application for post conviction relief Juvenile case Petition for habeas corpus Appeal from Family Court Case brought by a prisoner in the custody of the Department of Corrections Pro se representation Petition for extraordinary relief (including prerogative writs) Criminal case (including cases on review from municipal court or traffic court) DOES THIS APPEAL INVOLVE ANY OF THE FOLLOWING: State or federal constitutional interpretation Multiple parties Validity of state statute, ordinance or agency requirement Motions to intervene (if known) Inconsistency in decisions of Supreme Court Motions to file amicus briefs (if known) Motion(s) to stay appeal pending resolution of a related case Issue of first impression Other procedural complexity: ___________________________________________ PLEASE STATE ANY OTHER FACTORS AFFECTING THE APPROPRIATENESS OF THIS CASE FOR MEDIATION

HAS THIS CASE OR A RELATED CASE BEEN BEFORE THE SUPREME COURT PREVIOUSLY? NO YES/CASE NO. ________________ ANY COMPANION CASES? NO YES/CASE NO. _________________ BRIEFLY DESCRIBE THE JUDGMENT/RULING APPEALED

MAJOR POINTS OF ERROR OR ISSUES THAT ARE THE FOCUS OF THE APPEAL

PLEASE DESCRIBE THE FACTS THAT GAVE RISE TO THE INITIAL DISPUTE

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RHODE ISLAND SUPREME COURT APPELLATE MEDIATION PROGRAM PART I. MEDIATION ELIGIBILITY FORM Continued
CASE NAME TRIAL COURT CASE NUMBER:

HISTORY OF SETTLEMENT NEGOTIATIONS, IF ANY (Include a listing of all demands and counteroffers)

DESCRIPTION OF MONETARY, PHYSICAL INJURY OR ANY OTHER DAMAGES UPON WHICH THE CLAIM FOR COMPENSATION IS BASED

OUT-OF-POCKET EXPENSES UPON WHICH THE CLAIM IS BASED

PLEASE LIST NAMES AND ADDRESSES OF ALL OTHER COUNSEL INVOLVED IN THIS MATTER AND THE PARTY THAT HE OR SHE REPRESENTS

NAME

SIGNATURE

DATE

*If this appeal fits any one of the listed ineligibility categories, you need not complete Part II of this form. Send a copy of Part I to opposing counsel and the original and two copies to the Appellate Mediation Program, Rhode Island Supreme Court, 250 Benefit Street, Providence, Rhode Island 02903 Telephone: (401)222-8661. If your case is eligible for mediation, please complete Part II.

RHODE ISLAND SUPREME COURT APPELLATE MEDIATION PROGRAM PART II: CONFIDENTIAL MEDIATION STATEMENT AND AUTHORIZATION
FILL OUT PART II ONLY IF YOUR CASE IS ELIGIBLE FOR MEDIATION This form is for the use of the mediator only ­ DO NOT SEND COPIES TO COUNSEL
CASE NAME: NAME OF COUNSEL FILING STATEMENT FOR MEDIATION SESSION PLEASE LIST IMPORTANT FACTORS AFFECTING YOUR CLIENT'S CHANCES FOR SUCCESS ON APPEAL TRIAL COURT CASE NUMBER:

PLEASE DESCRIBE WHY PAST EFFORTS TO RESOLVE THIS DISPUTE HAVE BEEN UNSUCCESSFUL

WHAT ARE YOUR CLIENT'S TOP PRIORITIES/INTERESTS IN ORDER OF IMPORTANCE

PLEASE PROVIDE A LIST OF ACCEPTABLE OUTCOMES TO THE MEDIATION SESSION

LOWEST ACCEPTABLE SETTLEMENT VALUE

HIGHEST ACCEPTABLE SETTLEMENT VALUE

ARE THERE ANY OTHER RELATED ISSUES OR RELEVANT INFORMATION THAT WOULD ASSIST THE MEDIATOR IN THE RESOLUTION OF THIS CASE?

Attach a copy of the relevant order(s), memoranda, and opinions from which this appeal has been taken. If you are the appellant(s) or cross-appellant(s), you are required to attach a copy of the trial court's written decision(s) or order(s). Counsel may submit additional sheets as necessary to supplement this form.
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RHODE ISLAND SUPREME COURT APPELLATE MEDIATION PROGRAM CONFIDENTIALITY REQUIREMENT AND NEGOTIATION AUTHORIZATION I hereby agree that any and all documents submitted and statements made in furtherance of mediation, including, but not limited to, the content of this mediation eligibility form, mediation statement and any attachments thereto, and any relevant memoranda or supporting documentation relied upon during the course of the mediation session by counsel, any party or the mediator shall remain confidential. My client(s) further agrees not to subpoena or otherwise subject the mediator, staff members, or records of the Appellate Mediation Program to any court proceedings, lawsuits or other legal actions related to the mediation process or its outcome. My client(s) agree to participate in mediation, and I am authorized to participate and negotiate on behalf of my client(s) with full authority to make and/or accept offers. If I am not so authorized at the time of mediation, I will make arrangements to have my client(s) or authorized representative(s) available in person or by telephone at the time of the mediation session. I understand, and my client(s) have been informed that if an agreement is not reached, the case will be returned to the normal appellate process pursuant to the Rhode Island Supreme Court Rules of Appellate Procedure. If an agreement is reached, the case will be withdrawn and the mediator-justice may enter an appropriate order. Any agreement reached during mediation will have the full force and effect of a contract. I understand and my client(s) have been informed that failure to abide by the above requirements and/or Provisional Rule A may result in sanctions. I certify that a copy of the foregoing confidential mediation statement was executed truthfully and accurately to the best of my knowledge and a copy provided to the Appellate Mediation Program, Rhode Island Supreme Court, 250 Benefit Street, Providence, Rhode Island 02903.

PRINT NAME:

Counsel for:_________________________________

CASE NAME: _______________________________________ CASE NUMBER:____________________________ SIGNATURE: DATE: _____________________________________

Do NOT send a copy of Part II to counsel. Send this original form (and any attachments) and two complete copies to: Appellate Mediation Program Rhode Island Supreme Court 250 Benefit Street Providence, Rhode Island 02903 Telephone: (401)222-8661 www.courts.ri.gov