Free Mediator Statement - New Hampshire

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

MEDIATOR STATEMENT
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

So Ordered:
Date Signature of Judge

Printed Name of Judge

NOTE: Mediators must attach a copy of the order appointing them as mediator.
NHJB-2389-F (12/07/2006) Page 1 of 1