Case #            _____________________________________________________________________

Case Name:    _____________________________________________________________________

The undersigned parties agree to engage in mediation and to employ the services of Sarah E. Worley as mediator. In so doing, the undersigned acknowledge that the Mediation Rules of Sarah E. Worley Conflict Resolution, P.C. are applicable to the mediation of this matter and are incorporated herein by reference.

The undersigned further agree that:

1. The fee for the mediation of this matter is $                 per party for each mediation. Additional time shall be billed at $300.00 per hour to be divided equally among the parties.
2. The mediator’s work product, including notes, case file, and any other materials pertaining to the mediation are confidential and shall not be subject to disclosure in any legal or administrative matter or setting.
3. Any communications in any form made by any party in the course of the mediation shall be deemed confidential and shall not be subject to disclosure in any legal or administrative matter or setting.
4. Neither Sarah E. Worley nor Sarah E. Worley Conflict Resolution P.C. shall be liable to the undersigned for any act or omission in connection with the mediation.
5. In the event that this agreement is executed in counterparts, each counterpart shall be deemed to be an original document and each shall be considered to be the one and same valid mediation agreement.

The undersigned agree that, as the result of the mediation held on ______________, they have settled this matter for the following amount: ________________________. The undersigned further agree that they will prepare and execute formal release documents.