Fill and Sign the Name and Address of Mediation Center Form

STATE OF NORTH CAROLINA (specify just cause for waiver) the parties and/or mediator request a later court date be set to give more time for mediation of this case. The requested court date is: at AM. PM. an agreement was reached, however, the parties ne ed time to effectuate the terms of the agreement. Pending satisfactory outcome of the mediation agreement, the parties will req uest dismissal on the continued court date of at AM. PM. an agreement was reached and the parties req uest dismissal this date. no agreement was reached and the parties do not seek more time to mediate this matter. As a result of mediation, 1. has be en paid and a receipt is attached. has not be en paid and the parties and/or mediator req uest a fee waiver pursuant to G.S. 7A-38.7(a) for the following reason: In accordance with G.S. 7A -38.7, the dispute resolution fee 2. Name Of Defendant REPORT OF MEDIATOR Description Of Charge STATE VERSUS Name And Address Of Mediation Center Telephone No. Of Mediation Center G.S. 7A-38.3D; 7 A-38.5; 7A-38.7 Rules 5.B(2); 6.B(1)(j); 6.B(5) of Criminal Court Mediation AUTHORIZING SIGNATURES Name Of Complainant (Type Or Print) Name Of Defendant (Type Or Print) Signature Of Complainant Signature Of Defendant MEDIATOR SIGNAT URE(S) Name Of Mediator (Type Or Print) Date Name Of Mediator (Type Or Print) Date Signature Of Mediator Signature Of Mediator Date DateFile No. Co unty In The General Court Of Justice District Court Division Original - District Attorney, then to file Copy - Community-Mediation Center AOC-CR-700, Rev. 12/12 © 2012 Administrative Office of t he Courts Date Name Of Judge (Type Or Print) Signature Of Judge ORDER ON FEE (IF WAIVER REQUESTED) does not find just cause to waive the mediation fee in G.S. 7A -38.7(a) and therefore the fee remains due. In light of the fee waiver request in item no. 2 above, the undersigned judge hereby (select one) finds just cause to waive the mediation fee in G.S. 7A -38.7(a), as ordered on the attached AOC-CR-618. Other: . .