BTXN 002 (rev. 2/99)
UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS
ALTERNATIVE DISPUTE RESOLUTION SUMMARY
1. 2. 3. 4. 5.
Bankruptcy Case No.: ____________________________________________________ Date session(s) held: _____________________________________________________ Duration (i.e., half day, two days): __________________________________________ Your total fee? $ ________________________________________________________ Outcome of ADR (select one): " Parties did not use my services " Settled as a result of ADR " Settled in part as a result of ADR " Parties were unable to reach settlement
6.
Provider
Please list all persons in attendance (including party association):
7.
Please provide the names, addresses, and telephone numbers of counsel on the reverse of this form. Provider Information:
Address
8.
Signature
Date
City, State ZIP
Phone
Suite
Provider must file completed form in duplicate with the Bankruptcy Clerk.
Please provide the names, addresses, and telephone numbers of counsel in the space provided below.
Name
Name
Firm Name
Firm Name
Address
Address
City, State ZIP
City, State ZIP
Telephone
Telephone
Name
Name
Firm Name
Firm Name
Address
Address
City, State ZIP
City, State ZIP
Telephone
Telephone
Name
Name
Firm Name
Firm Name
Address
Address
City, State ZIP
City, State ZIP
Telephone
Telephone
Name
Name
Firm Name
Firm Name
Address
Address
City, State ZIP
City, State ZIP
Telephone
Telephone