Free Court-Funded Mediation Invoice, SCA-FC-505 - West Virginia

COURT-FUNDED MEDIATION INVOICE
MEDIATOR PAYMENT INFORMATION
Mediator: _______________________________________________________ Make check payable to: _____________________________________________ Address for remittance: _____________________________________________ ____________________________________________ Phone(home): _____________________________ Fax:_________________________
Return ORIGINAL invoice to: Pepper Flenner WV Supreme Court 1900 Kanawha Blvd East Building 1, Room E-100 Charleston, WV 25305

Phone (work):_________________________________

E-mail address:_____________________________________________________

Payee's SS # or F.E.I.N. (Whichever applicable): ______________________________________

HOURS AND MILEAGE: (each party must file an approved financial affidavit to qualify)
Number of hours worked ______ @ $45.00/hour = $_________ Total fees County where mediation occurred:______________________________________ Case # ____________________________ originating in County of ___________________________________ If you traveled outside of your home county to mediate, provide the following information for mileage reimbursement County traveled to: ____________________________________ Your home county: ____________________________________ Round trip miles traveled ______________ x $0.______ per mile =

$ _________ Total mileage

Add total fees + total mileage =

$ _______ Total due

Paid through Parent Education and Mediation Fund 1759 Sign here in blue ink:
For Administrative Office Use Only

Date:

Approved by:________________________________________________________________ Date:

_____________

SCA-FC-505

(12/07)

Mediator:_______________________________________ County:_____________________ Case # ______________________ Mediation Date: ____________

PARTIES CONTACT INFORMATION (addresses REQUIRED for payments to be rendered)
(1) Name:______________________________________________ Address: Approved financial affidavit

______________________________________________________ ______________________________________________________

Daytime phone:____________________________ Evening phone: ___________________________ (2) Name:______________________________________________ Address: Approved financial affidavit

______________________________________________________ ______________________________________________________

Daytime phone:_____________________________ Evening phone: ___________________________

MEDIATION INFORMATION:
Date(s) of session(s): ___________________________ County where session held:___________________________

Time spent in mediation: _________ hours _________ minutes Administrative time spent outside of mediation: _________ hours _________ minutes

MEDIATION OUTCOME REPORT:
Was an agreement reached during the mediation session? Was agreement reached before session began? These parties failed to attend: Mother Yes No Yes, partial agreement No

Yes, full agreement Both Yes

Father

Did anyone in addition to the two parties attend the mediation?

No

If yes please list the following information regarding the additional person(s) in attendance: (a) Name: ________________________________________ Relationship to party: _______________________ (b) Name: ________________________________________ Relationship to party: ______________________

SCA­FC-505 (12/07)