CAO SC 4-4
MEDIATION INTAKE SUMMARY

Date of Mediation 		Date Case Filed: 				

Mediators: 		Small Claims Case No. 			

								

Plaintiff: 		Defendant: 					

Address: 		Address: 					

   Day Phone: 		   Day Phone: 				
   Evening Phone: 		   Evening Phone: 				

Please indicate with an X whether party prefers to be called day or evening.
								
TYPE OF CASE
     Landlord/Tenant             Automobile Accident             Property
     Commercial Dispute: 								
     Interpersonal Dispute: 								
     Other: 								
Judgment sought by Plaintiff: 								

SETTLEMENT

    SETTLED – Terms: 								

     PARTIAL SETTLEMENT – Terms: 																

     NOT SETTLED
Who ended the mediation?  Plaintiff      Defendant      Mediators      All 

Is party willing to be called for follow up information? Plaintiff        Defendant   
	          	Yes    No       Yes    No

		(Please circle appropriate response)