Appendix D Record of Termination

_______________________________________

Initiating Party

Case No. _____________

_______________________________________

Responding Party

Date _________________

Starting Time ___________

Ending Time ___________

If a mediation session was not held, indicate whose absence was responsible: (a.) Initiating party, (b.) responding party, or (c.) both parties. _________

If a mediation session was held, please complete the remainder of this record.

1. Nature of Dispute (briefly describe)

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

2. Relationship of Parties (briefly describe)

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

3. Persons, other than the parties, present at mediation (name, address, telephone, relationship)

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

4. Indicate at what stage the mediation session terminated:

____ Introduction

____ Information exchange Negotiations

____ Agreement