UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE
SAMPLE
v. Civil No. _______________
CONSENT TO MEDIATION
The parties in the above-captioned matter agree that ___________________________ is an acceptable mediator. It is further agreed that both counsel and parties will participate in good faith and shall cooperate with the mediator. The parties have agreed to pay (directly to mediator) the $____ hourly rate as follows: _______________________________________________________ _______________________________________________________ _______________________________________________________
_____________________________ Counsel for Plaintiff Date _____________________________ Counsel for Defendant Date
______________________________ Plaintiff Date ______________________________ Defendant Date
(Form to be sent directly to MediatorĀDO NOT FILE WITH COURT)