REQUEST FOR MEDIATION

1. Request for a mediation of a dispute. The Requesting Party identified below hereby initiates mediation pursuant to an agreement, a copy of which is enclosed. Requesting Party encloses the $200 non-refundable mediation filing fee and summarizes the dispute on the next page.
2. Requesting Party. The name, address, and telephone number of Requesting Party and the Requesting Party's attorney (if any):


Requesting Party:    Attorney for Requesting Party:
Name: ______________________________    ______________________________

Address: ____________________________    ______________________________

______________________________

______________________________

Telephone (daytime): _____________________

Telephone (evening): _____________________
   ______________________________


3. Opposing Party. The name, address and telephone number of Opposing Party and its/their attorney (if any):


Opposing Party:    Attorney:
Name: ______________________________    ______________________________

Address: ____________________________    ______________________________

______________________________

______________________________

Telephone (daytime): _____________________

Telephone (evening): _____________________
   ______________________________


(attach separate sheet to name Additional Opposing Parties)





SUMMARY OF THE CLAIM NOW BEING DISPUTED
The following is a brief summary of the claim(s) of the Requesting Party (or any claim of the Opposing Party), the relief sought, the dollar amount of any money demand, whether interest is claimed, whether attorney's fees are claimed (and, if so, whether based on contract or statute), and, to the extent known, the denial or defense to such claim(s):






(Attach extra page if necessary)


Date: ______________________________

Signature of Requesting Party or Requesting Party's Attorney: ______________________

Print signer's name: _________________________________

Representative capacity: _________________________________

(Attorney, President, Partner, Party, etc.): _________________________________

Filing Instructions: Mail or deliver this Request for Mediation to Arbitration Service of Portland with your non-refundable filing fee check or money order for $200.00 payable to "Arbitration Service of Portland." Enclose a copy of the Agreement (if any) that suggests or requires mediation.

 

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