Fill and Sign the Only One of the Two Sections Sign below and Form

STATE OF NORTH CAROLINA SECTION 2 - MOTION FOR COURT APPOINTMENT OF MEDIATOR The above named case was referred to a mediated settlement conference. Signature Of Attorney (Or Pro Se Party) The above named case was referred to a mediated settlement conference. The parties have selected the mediator named below who has agr eed to serve in this case and is certified purs uant to the Rules Of Mediated Settlement Conferences. SECTION 1 - NOTICE OF SELECTION OF CERTIFIED M EDIATOR BY AGREEMENT Name And Address Of Certified Mediator Telephone No. FAX No. (if applicable) Mediator's Email Address DESIG NATIO N O F MEDIATOR IN SUPERIOR COURT CIV IL AC TIO N The parties have be en un able to agree up on the selection of a mediator and move the Senior Resident Superior Court Judge to ap point a certified mediator to con duct their conference. Name Of Attorney (Or Pro Se Party) Date As an aid to mediator selection, the NC Dispute Resolution Commission maintains a list of certified superior court mediators at www.ncdrc.org. Click on "List of Mediators" from the left-hand menu then click on "Mediated Settlement Conference Program." You may search for mediators by name or by judicial district. Once a mediator's name appears on your screen, click on it f or a complete contact and availability listing. NOTE: The parties and the mediator have agr eed upon the mediator's rate of c ompensation as follows: (specify all terms of the compensation agreement.) NOTICE: Plaintiff's attorney should check and fill out only one of the two Sections, sign below, and return to the Senior Res ident Supe rior Court Jud ge within 21 days after the date of the Order for Mediated Settlement Conference and distribute copies as noted below Tentative Trial Date G.S. 7A-38.1; Rule 2 of Mediated Settlement Conferences Original-File Copy-Senior Resident Superior Court Judge or his/her designee Copy-Plaintiff Copy-Defendant Copy-Mediator (Over) County In The G eneral Cou rt O f Justice S upe rior Court Division AOC-CV-812, Rev. 3/13 © 2013 Administrative Office of the Courts Name Of Plaintiff(s) Name Of Defendant(s) VERSUS Name And Address Of Defendant's Attorney (Or Pro Se Defendant's Address) Name And Address Of Plaintiff's Attorney (Or Pro Se Plaintiff's Address) Plaintiff's Attorney's Email Address (Or Pro Se Plaintiff's Email Address) Defendant's Attorney's Email Address (Or Pro Se Defendant's Email Address) Telephone No. FAX No. (if applicable) Telephone No. FAX No. (if applicable) File No. Date Of Order Referring Matter To Mediation Trial Date Deadline For Completion Of Mediated Settlement Conference AOC-CV-812, Side Two, Rev. 3/13 © 2013 Administrative Office of the Courts T he pa rties having repo rted the ir failure to agree up on the selecti on of a m ediator or t he pa rties having fail ed to notify t he Cou rt of t heir selecti on or nomina tion of a m ediator within tw enty- one (21 ) da ys after this case was or dered to m ediati on, the Cou rt ap points t he followi ng certifi ed m ediator to con duct t he m ediated settlem ent con fer ence. Name And Address Of Certified Mediator Mediator's Ema il Address Telephone No. FAX No. (if app licable) Name Of Senior Resident Superior Court Judge (Type Or Print) Signature Of Senior Resident Superior Court Judge Date CERTIFI CATE OF SERVICE The un dersign ed he reb y certifies t hat on this date a c opy of t he for ego ing Desi gnation of M ediator in t he Supe rior C ourt Civil Acti on was serv ed on the abo ve-select ed m ediator and the pa rties at t he add resses below by placi ng a c opy of t he same in t he Unit ed States Mail, po stage prepa id. (Pl ease provide names and addresses for the mediator and parties served in the spaces below. Attach additional sheets if necessary.) Signature Of Party or Party's Attorney Date Na me A nd Add res s O f Mediator Na me A nd Add ress Of Party Or Attorney Name Of Party (Type Or Print) NOTICE TO MEDIATOR: The mediator shall be responsible for reserving a place and making a rrangements for the conference and giving timely notice to all attorneys and unrepresented parties of the time and location of the conference. The mediated settlement conference shall be completed by the completion deadline set forth above, and the mediator shall report the results of the conference to the Court within ten (10) days aft er the conference is completed. O RD ER OF APP OINTMENT Name A nd Add ress Of Party Or Attorney Na me A nd Add ress Of Party Or Attorney Na me A nd Add ress Of Party Or Attorney Na me A nd Add ress Of Party Or Attorney Na me A nd Add ress Of Party Or Attorney Na me A nd Add ress Of Party Or Attorney