THE STATE OF NEW HAMPSHIRE
Court Name: Case Name: Case Number:
NAME AND ADDRESS OF PAYEE:
Name of Mediator if different from Payee Social Security or Federal I.D. Number of Payee
TYPE OF BILLING: 1. Divorce/Parenting Mediation payable through the Mediation fund (maximum compensation is $300): $300 Flat Fee for Mediation $120 Failure to Appear Fee INVOICE TOTAL 2. Adoption Mediation: $350 Flat Fee for Mediation INVOICE TOTAL $ $
I represent that the foregoing is a true and reasonable bill for services rendered.
Date Signature of Mediator
I hereby certify that I have examined the above statement and find the charge of $ to be reasonable. Recommended:
Date Signature of Marital Master
Printed Name of Marital Master
Date Signature of Judge
Printed Name of Judge
NOTE: Mediators must attach a copy of the order appointing them as mediator.
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