Response To Request To Mediate Response to Request to Mediate If you are a human and are seeing this field, please leave it blank. Party responding to 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 Do you have authority to enter into and sign a binding written agreement to settle this on behalf of the party you represent? YesNo Brief response to claim I/We agree to mediate with the requesting party to resolve this issue YesNo I have signed a payment voucher. YesNo I will be responsible for my portion of the fees incurred in this mediation. YesNo