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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 $300 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: |
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Attorney for Requesting Party: |
| Name: ______________________________ |
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______________________________ |
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| Address: ____________________________ |
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______________________________
______________________________
______________________________ |
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Telephone (daytime): _____________________
Telephone (evening): _____________________
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______________________________ |
| 3. |
Opposing Party. The name, address and telephone number of Opposing Party and its/their attorney (if
any): |
| Opposing Party: |
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Attorney: |
| Name: ______________________________ |
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______________________________ |
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| Address: ____________________________ |
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______________________________
______________________________
______________________________ |
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Telephone (daytime): _____________________
Telephone (evening): _____________________
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______________________________ |
(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 $300.00 payable to "Arbitration Service of Portland." Enclose a copy of the Agreement (if any) that suggests or requires mediation.
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