What is required for e-signature validity?

An electronic signature is valid if intent, consent, signer attribution, and record retention are satisfied. Follow the ESIGN Act and your state’s UETA rules to confirm that the submission method preserves these elements.

Can I electronically sign a mediation statement?

Yes, most mediation statements can be e-signed provided the mediator and local rules allow electronic submissions and the process preserves intent and an audit trail; some courts or mediators may impose authentication requirements.

Should exhibits be attached or referenced?

Attach numbered exhibits when feasible and reference them in the statement. If file size or confidentiality limits apply, provide a numbered exhibit index and indicate how the mediator will access the supporting materials.

Who should receive the statement?

Follow mediator or court directions. Typically the mediator and all parties receive exchanged copies unless the mediator requests submissions for mediator eyes only, in which case confidentiality must be stated.

Is the mediation statement confidential?

Confidentiality depends on the mediator’s rules, court orders, and any agreed protective orders. State and local rules govern disclosure; label privileged content and follow the mediator’s instructions to protect sensitive information.

How long must I retain the signed statement?

Retain signed mediation statements for the active case period and beyond; use retention guidance such as three years for tax-related records and six years for HIPAA-regulated records where applicable.

Electronic Signature
Templates
Legal
Mediation Statement Form

Mediation Statement Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Mediation Statement Form

This Mediation Statement is submitted on by Client Name: (Submitting Party) and Opposing Party Name: in the matter captioned Case Name: , Case Number: , Court: . Mediator: . Mediation Date:

RECITALS

WHEREAS, a dispute has arisen between the Submitting Party and the Opposing Party concerning the matters identified above and the parties have agreed to submit certain claims and defenses to mediation for the purpose of reaching a negotiated resolution; and

WHEREAS, the parties recognize that a concise written statement summarizing positions, factual contentions, legal theories, evidentiary matters and settlement history will assist the mediator in conducting an effective mediation session; and

WHEREAS, the parties and their counsel intend that this Mediation Statement be treated in confidence in accordance with the mediation agreement and applicable mediation privilege and shall be used solely for settlement discussions and mediator evaluation.

NOW, THEREFORE, the parties submit the following statement to the mediator.

1. IDENTIFICATION OF PARTIES AND COUNSEL

Submitting Party Representative (if different from party): Submitting Party Counsel (firm and lead counsel): Opposing Party Representative (if different from party): Opposing Party Counsel (firm and lead counsel):

2. STATEMENT OF ISSUES

Identify the principal disputed issues to be addressed at mediation, including discrete legal and factual questions, and any threshold issues the mediator should be aware of.

3. FACTUAL SUMMARY

Provide a concise, chronological summary of the facts relied upon, identifying key events, dates, locations, and factual disputes. Indicate facts that are undisputed.

4. LEGAL THEORIES AND DEFENSES

Summarize the controlling legal theories, statutory or contractual provisions relied upon, and principal affirmative defenses. Cite key authorities if necessary.

5. DAMAGES, RELIEF SOUGHT, AND OFFSET

State the nature and amount of claimed damages, the method of computation, and any non-monetary relief sought. If punitive or exemplary damages are claimed, describe the basis and amount sought.

Monetary damages claimed (aggregate): Types of relief sought (check applicable):

Compensatory Punitive/Exemplary Declaratory Injunctive

6. SETTLEMENT HISTORY

Provide a brief chronology of settlement negotiations, offers and counteroffers, demand amounts, and any prior mediation or ADR efforts.

7. PROPOSED TERMS OF SETTLEMENT

State the terms the submitting party is willing to accept, including payment schedule, releases, confidentiality obligations, and other material conditions.

8. EXHIBITS, EVIDENCE AND WITNESSES

List documents and other exhibits that the party intends to rely upon, and identify witnesses who may be offered for factual or expert testimony at mediation or in subsequent proceedings.

Primary exhibits or documents to be shown: Expected witnesses (name and subject matter):

9. CONFIDENTIALITY, PRIVILEGE AND USE

This Mediation Statement and any attachments are submitted in confidence for settlement purposes. The parties agree that, to the fullest extent permitted by law, the contents of this Statement and all communications made in connection with the mediation are privileged and inadmissible in any subsequent proceedings, except as required to enforce a resulting settlement agreement or as otherwise required by operation of law.

Notwithstanding the foregoing, nothing in this paragraph shall be construed to prevent disclosure of information that is otherwise discoverable independent of the mediation process.

10. AUTHORITY TO SETTLE

The undersigned certifies that the person(s) attending the mediation on behalf of the submitting party will have full authority to discuss settlement and, subject to any stated limitations below, to agree to settlement terms without further approval. If authority is limited, describe the limitation.

Representative will have full settlement authority Representative has limited authority

If limited, explain limitation:

11. NOTICES

Provide contact information for formal notices relating to mediation and any settlement communications.

Notices for Submitting Party: Notices for Opposing Party:

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Mediation Statement shall be governed by the substantive law of the state of . This Statement, together with any written agreement executed by the parties in settlement of the dispute, constitutes the entire understanding of the parties with respect to the subject matter hereof. If any provision of this Statement is held invalid, unenforceable or void, the remaining provisions shall continue in full force and effect.

13. AMENDMENTS; WAIVER; COUNTERPARTS

This Statement may be amended only by a written instrument signed by the party to be charged. No waiver of any provision shall be effective unless in writing and signed by the waiving party. This Statement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

14. CERTIFICATION

The undersigned certify under penalty of perjury under the laws of the governing jurisdiction that the information contained in this Mediation Statement is true and accurate to the best of their knowledge and belief as of the date signed, except as expressly stated otherwise herein. The parties reserve all rights not expressly waived or limited herein.

Party A Name:

By:

Date:

Party B Name:

By:

Date:

What the Mediation Statement Form Is and when it’s used

A Mediation Statement Form is a concise, written summary that each party prepares before a mediation session to present positions, key facts, legal claims or defenses, and evidence. It helps the mediator understand the dispute, frames settlement options, and identifies witnesses or exhibits. Courts or mediators may set page limits, confidentiality rules, or exchange deadlines. The form can be submitted as a paper original or electronically and is often retained with the case file after mediation concludes.

Why a clear Mediation Statement Form matters

A well-prepared mediation statement streamlines the session, focuses negotiation, and preserves each party’s position in writing. It reduces surprises, helps the mediator prioritize issues, and creates a record of requests and offers for later reference.

Who prepares and reads mediation statements

Multiple participants rely on mediation statements to prepare and manage the session.

Individual parties and litigants who need to state their position, damages, or settlement range succinctly.
Attorneys and legal representatives who prepare legal arguments, exhibits, and procedural requests for the mediator.
Mediators and court administrators who review submissions to set agendas and identify evidentiary issues.

Essential parts of a professional Mediation Statement Form

A complete mediation statement is concise and organized so mediators and opposing parties can quickly assess strengths, weaknesses, and settlement posture.

Case Summary

Two- to three-sentence factual overview that orients the mediator, identifies the dispute, and highlights the central legal issues.

Claims & Defenses

Clear listing of legal claims and affirmative defenses with citations or statute references where applicable; avoid lengthy legal argumentation.

Evidence List

Numbered exhibits and witness names with short descriptors so the mediator can request documents or testimony efficiently.

Relief Requested

Specific settlement demand or range and any non-monetary terms sought, stated clearly to avoid ambiguity during negotiation.

Confidentiality

Statement about confidentiality or limits on disclosure, noting whether the submission is for mediator eyes only or shared with all parties.

Signature Block

Authorized signer name, role, contact details, and signature line with date and method of execution (electronic or wet ink).

Key identification and administrative fields to include

Case Number: Court or docket identifier

Party Names: Full legal names only

Mediator Name: Assigned mediator or panel

Exhibit List: Numbered exhibit references

Submission Date: Date of filing/submission

Contact Info: Phone and email for signer

Stepwise process to prepare and submit the mediation statement

Follow these sequential steps to produce a clear, timely, and exchange-ready mediation statement.

01

Draft: Prepare the concise statement and exhibit list.
02

Review: Confirm legal accuracy and page limits.
03

Exchange: Share with other parties per mediator rules.
04

Submit: Deliver to mediator by the specified deadline.

How to configure an online mediation statement workflow

Set up fields, authentication, and retention rules before sending to ensure compliance and a smooth e-signature process.

Field \| Configuration	Name \| Requirement
Document Template	PDF fillable \| Use a locked, uneditable template
Authentication	Email + SMS \| Two-factor where required
Signature Type	Simple e-signature \| Audit trail attached
Retention Policy	7 years \| Per counsel or court rules

Where to send the mediation statement and what happens next

Understanding routing ensures the mediator and opposing parties receive the completed form in the required timeframe.

Upload to Portal: Submit via court or mediator portal when available.
Email to Parties: Send certified or agreed email copies per instructions.
Deliver to Mediator: Provide the mediator the final signed statement.
Record Retention: Keep copies per retention policy and legal obligations.

Technical considerations for digital submission and signing

Confirm allowed file formats, signer authentication methods, and privacy controls before starting the e-signature workflow.

File formats: PDF, DOCX accepted
Integrations: Connectors: Salesforce, NetSuite, Microsoft 365
Security Standards: TLS 1.2/1.3; AES-256 at rest

Typical exchange and submission timelines to plan for

Mediators and courts set specific deadlines; use these typical timeline points to coordinate exchanges and filings.

Mediator Submission Deadline:

Typically 3–14 days before mediation depending on mediator rules.

Exchange Between Parties:

Often due 7–10 days before the session to allow responses.

Exhibit List Deadline:

Align exhibit delivery with the statement submission to avoid surprises.

Pre-mediation Brief:

Some mediators request a brief no later than five business days prior.

Court Filing:

If required, follow the court’s local rule for filing times and procedures.

Common preparation pitfalls to avoid

Submitting late or missing the mediator’s exchange deadline, causing exclusion or rescheduling of the session.
Including unnumbered or poorly described exhibits, which increases friction and disputes about admissibility.
Using vague settlement language such as 'reasonable amount' instead of a specific demand range.
Failing to authenticate the signer or provide authority documentation for corporate signatories.

Consequences of an incomplete or incorrect mediation statement

Evidence Exclusion: May be excluded

Scheduling Delay: Session rescheduled

Sanctions Risk: Court sanctions possible

Credibility Harm: Reduced mediator confidence

Financial Cost: Additional fees incurred

Waiver: Claims or defenses may be forfeited

Real-world examples of mediation statement use

These brief examples show how organizations have applied digital workflows to mediation submissions.

Optica Ventures LLC

Optica prepared streamlined mediation packets using fillable templates and e-signatures to speed exchanges and reduce errors.

The operation reduced administrative friction during intake and signing.
By standardizing the form and using a secure e-signature platform, Optica shortened preparation time and improved consistency across cases.

Fertility Centers of Illinois

The center adopted electronic statements to manage patient-sensitive disputes with added privacy controls.

Staff reduced document turnaround time while maintaining compliance.
Use of secure e-signature workflows allowed staff to coordinate mediator submissions while preserving audit trails and access controls.

eSignature vendor snapshot relevant to mediation statement workflows

Compare core pricing and feature dimensions for common eSignature vendors; signNow is listed first per platform details and pricing tiers.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no card	Varies by vendor	Varies	Varies	Varies
Bulk Send	Yes (Business Premium)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Verify with vendor	Verify with vendor	Verify with vendor	Verify with vendor
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Common questions about completing and e-signing a Mediation Statement Form

Answers to frequent practical and legal questions about mediation statements, signature methods, confidentiality, and retention.

Need help? Contact support

What is required for e-signature validity?
An electronic signature is valid if intent, consent, signer attribution, and record retention are satisfied. Follow the ESIGN Act and your state’s UETA rules to confirm that the submission method preserves these elements.
Can I electronically sign a mediation statement?
Yes, most mediation statements can be e-signed provided the mediator and local rules allow electronic submissions and the process preserves intent and an audit trail; some courts or mediators may impose authentication requirements.
Should exhibits be attached or referenced?
Attach numbered exhibits when feasible and reference them in the statement. If file size or confidentiality limits apply, provide a numbered exhibit index and indicate how the mediator will access the supporting materials.
Who should receive the statement?
Follow mediator or court directions. Typically the mediator and all parties receive exchanged copies unless the mediator requests submissions for mediator eyes only, in which case confidentiality must be stated.
Is the mediation statement confidential?
Confidentiality depends on the mediator’s rules, court orders, and any agreed protective orders. State and local rules govern disclosure; label privileged content and follow the mediator’s instructions to protect sensitive information.
How long must I retain the signed statement?
Retain signed mediation statements for the active case period and beyond; use retention guidance such as three years for tax-related records and six years for HIPAA-regulated records where applicable.

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Field \| Configuration	Name \| Requirement
Document Template	PDF fillable \| Use a locked, uneditable template
Authentication	Email + SMS \| Two-factor where required
Signature Type	Simple e-signature \| Audit trail attached
Retention Policy	7 years \| Per counsel or court rules