Number of party expected to attend mediation:

1. Mediation referral to John W. Hughes initiated by:

E-mail address:

Would you like a copy of this form e-mailed back to you? Yes No

2. Type of Case:

3. Names, addresses, and telephone numbers of Plaintiff parties
(identify authorized representatives, if known) and attorneys of record:

4. Names, addresses, and telephone numbers of Defendant parties
(authorized representatives, if known) and attorneys of record:

5. Names, addresses, and telephone numbers of other parties
(please specify, "Intervener", etc and identify authorized representatives, if known)
and attorneys of record:

6. The nature of Plaintiff's claims and the Defendant's defenses and counterclaims:

7. What relief is sought by parties:

8. What are the primary disputed issues of law or fact in this case from your perspective:

9. What is the status of discovery:
Little or None
Some discovery done but substantially incomplete
Complete or Substantially complete

10. Do you have sufficient information to form a realistic settlement position?
Yes No
If not, what else is needed?

11. What are the last offers of the parties?

ON BEHALF OF , ONE OF THE PARTIES IN THE ABOVE CAUSE, THE UNDERSIGNED ATTORNEY OF RECORD REQUESTS THAT JOHN W. HUGHES ACT AS MEDIATOR IN THE ABOVE CASE; AND WE AGREE TO BE BOUND BY THE RULES OF MEDIATION AND MEDIATION FEE CRITERIA PROVIDED BY THE MEDIATOR TO ME.

DATED: (Use this format: "January 1, 2000")

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