Mediation Form

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MUSKINGUM COUNTY COURT MEDIATION PROGRAM:::::::Index No.Calendar No.DATE:MEDIATION NO:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)CLAIMANT#1RESPONDENT#1 NameName AddressAddress City, State, ZipCity, State, Zip Phone:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone:CLAIMANT#2RESPONDENT#2 NameTHE PEOPLE OF THE STATE OF NEW YORK TOName AddressAddress City, State, ZipCity, State, Zip Phone:Phone:GREETINGS:Amount Claimed:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Nature of Claim (Check appropriate line(s): Money due on accountlocated at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomMoney lent Security depositRent Damage to real propertyPersonal property damage Faulty repair workMotor vehicle damage Wages/salaries/commissionsDishonored check Personal injuryYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Faulty goods or services Taxes/utilitiesFraud/misrepresentationOther:, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Claimant's Statement(Attorney must sign above and type name below)Attorney(s) forUse reverse side if necessaryOffice and P.O. AddressFor Mediator's Use Only Result:Mediator:Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com</document>