Fill and Sign the Instructions Please Type or Print and Mail along with Any Attachments to the N Form

1. 2. 3. 4. 5. Name of the mediator, mediation trainer or mediation training program that is the subject of your complaint . (If your complaint is against a trainer, indicate the training program with which h e/she is affiliated): If your complaint concerns a mediator, identify the disput e or court case which the mediator was selected or appointed to mediate and from which your complaint aro se. (If filed in court, please provide the case name and number assigned to your litigation by the Clerk. If the dispute in which you are or were involved has not been filed as a court case or assigned a number by the Clerk, list the principal parties involved:) If a mediation conference was held, give the date(s) on which it was conducted and the location of the conference: If your complaint involves a mediation trainer or traini ng program, indicate the date(s) on which you attended training and the location where the training was held : In the space below, please describe your complaint against the mediator, mediation trainer or training program named above and indicate all facts upon which your complai nt is based. (If necessary, add additional pages.): (Over) DISPUTE RESOLUTION COMMISSION COMPLAINT STATE OF NORTH CAROLINA AOC-DRC-05, Rev. 4/08 © 2008 Administrative Office of the Courts Telephone No. (Work Or Cell) Telephone No. (Home) Name And Address Of Complainant INSTRUCTIONS: Please type or print and mail along with any attachments to the N.C. Dispute Resolution Commissi on, P.O.Box 2448, Raleigh, NC 27602. AOC-DRC-05, Side Two, Rev. 4/08 © 2008 Administrative Office of the Courts Description of Complaint (continued from side one). Signature SWORN/AFFIRMED SUBSCRIBED TO BEFORE ME Title Of Person Authorized To Administer Oaths Date Signature Of Applicant Name Of Applicant (Type Or Print) Date SEAL Date Commission Expires County Where Notarized Notary I have furnished the above information to allow the Di spute Resolution Commission to investigate my complaint and I agree to cooperate with the Commission in its investigati on, including furnishing any evidence in my possession relati ng to this complaint and to my mediation or my mediation t raining. I further authorize any witnesses listed above, including my own attorney, if listed, to cooperate with the Commi ssion in its investigation and hearing of this matter and to provide information and/or documents to the Commission that mig ht otherwise be confidential including providing information or documents subject to the attorney-client privilege. I furt her agree that if a hearing is held in this matter that I will appear at the hearing or otherwise give evidence in support of my complaint. I understand that a copy of this complaint a nd any other information provided to the Commission may be shar ed with the mediator, mediation training program, or mediation trainer that is subject of this complaint. It may also be shared with witnesses listed above and with oth ers identified during the course of the Commission's investiga tion. 7.Please attach to this completed form copies of any correspondence or other documents which support your complaint. Name And Address Of Individual 1 Daytime Telephone No. Name And Address Of Individual 2 Daytime Telephone No. 6. Provide below names of all individuals who have knowledge of your above complaint and indicate how they may be contacted. (Add additional pages if necessary.):