Free REQUEST FOR ASSIGNMENT TO MEDIATION PROGRAM AND ASSIGNMENT OF MEDIATOR - Washington

ADR FORM #4 (4/00) UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF WASHINGTON ) ) ) Debtor(s) ) ______________________________) ) (If an Adversary Proceeding) ) Plaintiff(s) ) ) vs. ) ) ) Defendant(s) ) In re:

Bk. No.

Adv. No. REQUEST FOR ASSIGNMENT TO MEDIATION PROGRAM AND ASSIGNMENT OF MEDIATOR

It is requested that the below described issues in the above- entitled matter be assigned to the Mediation Program established by General Order of the Court dated January 24, 2000. In support of this request the following information is provided: Is this request for assignment on a pro bono basis? YES /___/ NO /___/ If YES, attach statement explaining why pro bono mediation is necessary. The procedural requirements established for the court's mediation program have been read and will be complied with if the matter is assigned to the program. YES /___/ NO /____/ The Bankruptcy Estate is a party to the matter to be mediated. YES /___/ NO /___/ The matter to be mediated is /___/ an Adversary Proceeding, /___/ a Contested Matter. Chapter Under Which Relief was Ordered /___/ 7, /___/ 11, /___/ 12, /___/13 The issue(s) to be mediated is (check all that apply): / / To Recover Money or Property The Amount of Money or Value of Property at Issue: $_____________ To Determine the Validity, Priority or Extent of a Lien or Other Interest in Property

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To Object to or to Revoke a Discharge (11 USC 727) To Determine the Dischargeability of a Debt (11 USC 523) An Objection to a Proof of Claim An Objection to the Confirmation of a Plan The Determination of the Value of Property To Recover a Voidable Preference or Fraudulent Transfer The Avoidance of a Lien Other (describe) ________________________________

It is further requested that the following mediator(s) appointed to the Panel of Mediators be assigned to mediate this matter, listed in the order of preference: ______________________________ Name ______________________________ Name ______________________________ Name Dated:_____________________

__________________________ party(s)

Represented by:

______________________________ (Signature) Name:________________________ Address:______________________ Telephone:____________________ Fax:__________________________ Email:________________________

Dated:____________________ _________________________ party(s)

Represented by:

_____________________________ (Signature) Name:________________________ Address:______________________ Telephone:_____________________ Fax:__________________________

Email:________________________ Request for Assignment To Mediation Program And Assignment of Mediator