Mediator Statement Voluntarily Mediated Adoption Or Minor Guardianship {NHJB-2682-F} | | New Hampshire

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Mediator Statement Voluntarily Mediated Adoption Or Minor Guardianship {NHJB-2682-F} |  | New Hampshire

Mediator Statement Voluntarily Mediated Adoption Or Minor Guardianship {NHJB-2682-F}

This is a New Hampshire form that can be used for First Appearance Or Mediation within Statewide, Family Division.

Alternate TextLast updated: 2/14/2014

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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: MEDIATOR STATEMENT VOLUNTARILY MEDIATED ADOPTION / MINOR GUARDIANSHIP1 Name of Payee Address of Payee Name of Mediator if different from Payee Social Security or Federal I.D. Number of Payee TYPE OF BILLING: Adoption Mediation ($350 Flat Fee for Mediation) Case Number: Case Number: Case Name: Case Name: Minor Guardianship Mediation ($350 Flat Fee for Mediation) INVOICE TOTAL $ 0.00 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 NOTE: Mediators must attach a copy of the order appointing them as mediator. 1 This form should be used for Voluntarily Mediated Adoptions and Minor Guardianship Cases when the mediation fee is paid from the Office of Mediation fund. This form should be sent to the Administrative Office of the Courts for Payment. NHJB-2682-F (02/28/2011) American LegalNet, Inc. www.FormsWorkFlow.com

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