Request To Mediate Request to Mediate If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Amount of money involved: * Party requesting mediation * BuyerSellerBrokerListing AgentOther First Name * Last Name * Address 1 * Address 2 City * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Name of Legal Counsel or other Representative Legal Counsel's Phone Legal Counsel's Email Brief description of claim Have there been any formal court pleadings filed in this case? YesNo If yes, are there any trial dates or time limitations involved? YesNo Hearing Date Court Case # Judge Do you have authority to enter into and sign a binding written agreement to settle this on behalf of the party you represent? YesNo During the four-week period following the date you submit this request, list the dates you would be available for a mediation conference Other parties to the dispute BuyerSellerBrokerListing AgentOther Other Party First Name Other Parties Last Name Other Parties Address 1 Other Parties Address 2 Other Parties City Email Phone Other Parties State Alabama Alaska Arizona Arkansas California Colorado Connecticut Zip / Post Code Other Party's First Name Other Party's Last Name Other Party's Address 1 Other Party's Address 2 Other Party's City Other Parties State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Zip / Post Code Email Phone Other Party's First Name Other Party's Last Name Other Party's Address 1 Other Party's Address 2 Other Party's City Other Parties State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Zip / Post Code Email Phone
