UNITED STATES DISTRICT COURT Case No.: FOR THE MIDDLE DISTRICT OF NORTH CAROLINA DIVISION
Name of Plaintiff(s):
Name of Defendant(s):
Name and Address of Mediator:
The und ersigned m ediator repo rts the follow ing results of a mediated settlement conference ordered in this case: Conference [ ] [ ] was held. was not held.
If not h eld, the reaso ns were: .
Numb er of conf erences he ld: Date of c onferenc e was co mpleted: Place wh ere confe rence wa s held: Numb er of particip ants presen t: Numb er of obse rvers: List name of parties, attorneys, insurance re presentatives, or other who were present: SEE BACK OF FORM The parties reached an: [ ] agreement on all issues. [ ] agreement on some issues. [ ] impasse. If the case was no t settled, estimated length of trial (number o f days) If there wa s partial agree ment, list issues s ettled: Any agreement reached will conclude the lawsuit as follows: [ ] by consen t judgeme nt. [ ] by voluntary dismissal(s). If the case was settled, the documents to be filed, and the persons who are to file them are as follows:
. . .
[ ] [ ] [ ]
Consent Judgement Voluntary Dismissal With Prejudice Voluntary Dismissal Without Prejudice
Filed B y:
Please return completed report to: Clerk of Court, POB 2708, Greensboro, NC 27402
MEDIATOR `S FEE For Information purpose, please report the following: Total Trav el Time: Hours Total M ediation Tim e: Hours Minutes Minutes TOTAL> All fees of the mediator have been paid except as follows: Name of Party Owing Balance Address of Party Amount of Balance $ $ $ $
DEFEN DAN T(S):
I have mailed this report within seven (7) days after conclusion of conference to the Office of the Clerk. Date: Signature of M ediator:
MDN C-Mediator R eport