Mediator Reaffirmation Of Qualifications {125}

UNITED STATES BANKRUPTCY COURT DISTRICT OF DELAWARE ANNUAL MEDIATOR REAFFIRMATION OF QUALIFICATIONS I, _________________________, the undersigned, hereby affirm the continued existence and accuracy of the qualifications, statements and representations made in my application for admission to the Register of Mediators for the United States Bankruptcy Court for the District of Delaware. In reaffirming these qualifications, I hereby certify under penalty of perjury that all of the following information is true and correct. 1. I have accepted at least one pro bono appointment for the current calendar year, or I have the ability to perform at least one pro bono appointment for the current calendar year, and; 2. I have _______ /have not ___________, been selected or appointed as a mediator in a dispute within the preceding three years. Dated: ,_____________ 201___ __________________________________________ Signature _________________________________________ Print or Type Name and last four digits of SS# __________________________________________ Address __________________________________________ __________________________________________ __________________________________________ Telephone Number: E-mail Address: Email Completed Reaffirmation of Qualifications to: Mediator_reaffirmation@deb.uscourts.gov American LegalNet, Inc. www.FormsWorkFlow.com