Response To Request To Mediate

Party responding to requesting mediation

First Name

Last Name

Address 1

Address 2

City

State

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?

Brief response to claim

I/We agree to mediate with the requesting party to resolve this issue

I have signed a payment voucher.

I will be responsible for my portion of the fees incurred in this mediation.

Response to Request to Mediate