Mediation Certificate Form

Mediation Certificate Form

This Mediation Certificate is executed by Mediator Name: and Authorized Representative: concerning the matter captioned Case Name: , Case Number: in Jurisdiction: .

Recitals

WHEREAS, the parties to the above-captioned matter agreed to submit their dispute to private mediation conducted by a neutral mediator for the purpose of exploring settlement and narrowing issues in dispute; and

WHEREAS, the mediation session was scheduled and held at Location: on Date: , for a total duration of hours.

WHEREAS, the mediator is duly qualified and authorized to mediate disputes, License/ID No.: , and has provided neutral facilitation in accordance with accepted mediation practice.

NOW, THEREFORE, in consideration of the foregoing recitals and the mutual covenants contained herein, the mediator certifies the following.

1. Certificate of Mediation

I, the undersigned mediator, hereby certify that on the mediation date indicated above I conducted a mediation session concerning the captioned matter. The mediation was conducted with the intention of facilitating settlement and included the parties and/or their duly authorized representatives listed in Section 2 below. The mediation concluded as indicated by the outcome field below.

Mediation Outcome: Settlement Reached Partial Settlement No Settlement

Additional details regarding outcome (if any):

2. Attendance

The following persons participated in the mediation session in the capacities indicated (name and role):

3. Confidentiality

The parties and the mediator acknowledge that communications, statements, and writings made for the purpose of, in the course of, or pursuant to the mediation are confidential and are not admissible in evidence, except as otherwise required by statute or where disclosure is necessary to enforce a written settlement agreement, to apply for a court order to enforce an agreement, or to prevent a manifest injustice. Nothing in this certificate constitutes a waiver of confidentiality protections available under applicable law.

4. Effect on Proceedings

This certificate is a statement that mediation occurred and may be submitted to the court or tribunal for administrative purposes where allowed. This certificate is not, in itself, an admission of liability nor does it alter any party's substantive rights except as provided by a separately executed written settlement agreement.

5. Fees and Costs

Total Mediator Fees Incurred:

Fees Paid By:

6. Notices

All notices related to this certificate shall be in writing and delivered to the addresses provided below. Delivery by hand, private carrier, or certified mail shall be effective upon receipt.

7. Governing Law

This certificate shall be governed by and construed in accordance with the substantive laws of the jurisdiction designated above, without regard to conflict of laws principles.

8. Miscellaneous

Entire Agreement. This certificate, together with any written settlement agreement executed by the parties, constitutes the entire understanding between the parties with respect to the matters certified herein.

Amendments; Waiver. No amendment, modification, or waiver of any provision of this certificate shall be effective unless in writing and signed by the mediator and the authorized representative of the parties. No waiver shall constitute a waiver of any other provision or future default.

Severability. If any provision of this certificate is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Counterparts. This certificate may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

Certification

I certify, under penalty of perjury under applicable law, that the foregoing statements are true and correct to the best of my knowledge and that the mediation described above took place as stated.

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