New Hampshire > Statewide > Family Division > Divorce And Parenting
Mediator Statement Divorce And Parenting NHJB-2681-FS - New Hampshire
| Mediator Statement Divorce And Parenting Form. This is a New Hampshire form and can be used in Divorce And Parenting Family Division Statewide . |
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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: MEDIATOR STATEMENT- DIVORCE AND PARENTING1 Name of Payee Address of Payee Name of Mediator if different from Payee Vendor # TYPE OF BILLING for Mediation payable through the Family Mediation Fund: $300 Fee for Mediation (5 hours Both parties Fund) $ Mediation fee for (name of party) $ Proportionate Fee for mediation (5 hours Party A- Fund) $ Proportionate Fee for mediation (5 hours Party B- Fund) $ Sliding Scale fee, if any 2 ( hours per hour). * Applies of mediation services at $ after the initial 5 hours of mediation time. reduced fee due to circumstances $ Mediation fee for (name of party) $120 Failure to Appear Fee NOTE: Mediators must attach a copy of the order appointing them as mediator. reduced fee due to circumstances Billing for Mediation Grant $300 Fee for Mediation (5 hours) $120 Failure to Appear Fee NOTE: Mediators must attach a copy of the order appointing them as mediator and Mediation Data Collection Form. 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: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge This form should be used when one or both parties have been approved to have the mediation fees paid through the Family/Indigent Mediation Fund or through the Mediation Grant. 2 Any amount billed after the initial fixed fee amount of $300 for 5 hours may only be billed after agreement by the parties and, if a Fund case, after a motion requesting the additional payment, consistent with the sliding scale, is granted by the Court. For the Mediation Grant the maximum amount to be billed is $300. NHJB-2681-FS (03/29/2012) American LegalNet, Inc. www.FormsWorkFlow.com 1
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