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Total Time Spent in Mediation: TOTAL FEE$$ $ $ $ $ POSTPONEMENT/CANCELLATION FEE (CMP RULE 7.F or as privately agreed with party-selected mediator ) Out-of Pocket Or Other Agreed Upon Fees (Not applicable To Clerk Appointed Mediator.) Mediation $ $ $ $ 125.00 a. b. c. MEDIATION FEE (CMP RULE 7.B.): ($125.00 per hour for time spent in conference for court-appointed mediator, billed in quarter hour segments, or privately set fee for party-selected mediator.) STA TE OF NORTH CA ROLINA Count y File No. In The General Court Of Justice Superior Court DivisionBefore the Clerk AOC-G-303T, New 3/06 © 2006 Administrative Office of the Courts M EDIA TOR' S FEE ADMINISTRATIVE FEE (CMP RULE 7.B. or as privately agreed with party-selected mediator) Hours Minutes If the matter was reported settled prior to or during a recess of the mediation, provide the name of the per son(s) who reported the matter settled: 1. The undersigned mediator reports the following results of a mediation ordered in this case: REPORT OF MEDIATOR IN CLERK PROGRAM MEDIATION VERSUS (IN THE M A TTER OF: ) G.S. 7A-38.3B; Rule 6.B.(4) Of Rules Implementing Mediation In Matters Before The Clerk Of Superior Court Name Of Respondent/Decedent Name Of Petitioner Name And Address Of Mediator Telephone No. impasse. was held. was not held. 6. If an agreement or partial agreement was reached in an estate, guardianship or other matter requiring Clerk review, the written agreement or partial agreement is attached to this report and offered to the Clerk pursuant to Rule 4.B(2). If not held, the reasons were: If held, date mediation was completed: 2. Names of parties, attorneys, interested persons, fiduciarie s, or others who were absent without permission: 3. 4. The participants reached an: agreement on all issues. agreement on some issues. ( ) Name, address and telephone number of party or attorne y who is to file the closing document: Telephone number: Date by which closing document will be filed: c. If the matter was settled and is resolved by the agreemen t, the following document is to be filed: 5. voluntary dismissal with prejudice. consent judgment. voluntary dismissal without prejudice. a. b. Name:Address: Signature of party or attorney who will file closing do cument: d. NOTE: NOTE:Closing documents shall be filed within 10 days or before expiration of t he mediation deadline, whichever is longer. Rule 4.B.(1). Complete subsection d below only if an agreement is reached on all issue s at the conference. Party-Selected Mediator Original-Clerk Copy-Petitioner Copy-Respondent Copy-Other Ordere d Persons/Entities (Over) Court-Appointed Mediator All fees of the mediator have been paid except as follows: AOC-G-303T, Side Two, New 3/06 © 2006 Administrative Office of the Courts This matter pertains to an estate or guardianship and n o fees have been apportioned or paid. Mediator, therefore, advises the Clerk of the need for apportionment of all fees above, pursuant to Rule 7.C. Name of any person(s)/entity(ies) filing motion for relief from obligation to pay mediator's fee: (Please attach motion for relief.) I have submitted this Report to the Clerk as required wi thin ten (10) days after conclusion of mediation. Signature Of Mediator Name Of Mediator (Type Or Print) Date Name Of Party Owing Balance Address Of Party Amount Of Balance