Form Cmr-240 - Consent Stipulation Of Mediator
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1NORTH CAROLINA
IN THE GENERAL COURT OF JUSTICE
DISTRICT COURT DIVISION
GUILFORD COUNTY
File No.
______________
_______________________________
Plaintiff
C O N S E N T S T I P U L A T I O N
v.
O F M E D I A T O R
(FAMILY FINANCIAL CASE)
_______________________________
Defendant
COMES NOW, the undersigned attorneys, or parties (if pro se) in this action, and do hereby stipulate and
agree that the following mediator shall serve as the mediator in this family financial action:
NAME:
______________________________________________
ADDRESS
______________________________________________
______________________________________________
PHONE NUMBER
______________________________________________
FAX NUMBER
______________________________________________
☐Certified Family Financial Mediator ☐Non-Certified Family Financial Mediator
The undersigned additionally hereby certify that the mediator named above has agreed to serve as mediator
in this action and that a copy of this Stipulation has been served on the aforementioned mediator in accordance
with Rule 5 of the North Carolina Rules of Civil Procedure.
SIGNATURE
SIGNATURE
NAME
______________________________
NAME
_____________________________
DATE
______________________________
DATE
_____________________________
Attorney for Plaintiff
Plaintiff
Attorney for Defendant
Defendant
☐
☐
☐
☐
ADDRESS
_____________________________
ADDRESS
_____________________________
_____________________________
_____________________________
PHONE NO. _____________________________
PHONE NO.
_____________________________
EMAIL
_____________________________
EMAIL
_____________________________
Note to Mediator:
The mediator shall be responsible for reserving a place and making arrangements 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 in the Standing Order or in another Order entered by the presiding Judge and the mediator shall report
the results of the conference to the Court within ten (10) days after the conference is completed or within ten (10) days of being advised by
a party that the case settled or was otherwise disposed of prior to mediation.
CMR-240
Rev. 12/2012
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