Financial Information Form

FINANCIAL INFORMATION FORM Mediation costs are assessed to each party based on the Mediation Sliding Fee Scale up to a maximum of $70.00 per hour. Payment for mediation costs will be determined and must be made before your session can begin. The Third Judicial District Court does not accept personal checks and there is not an ATM in the courthouse. You may pay with cash, money order or cashier's check. THERE IS NO ATM IN THE COURTHOUSE You must complete this form and bring it to the mediation with proof of your income such as paycheck stubs or your last income tax return. There is a Mediation Sliding Fee Scale with this packet that you can use to decide whether you will be entitled to a reduction of the mediation fee. Your Name: Employer Name-Address-Telephone No.: How long have you worked there? Gross monthly income (before any deductions): Monthly Income from other sources: Total monthly income: Do you work any overtime? Yes How often do you work overtime? No If yes, What is your overtime rate? I swear that the above response are true and correct. I agree to pay my share of the assessment for mediation. I understand that false statements or failure to pay may be considered as grounds for contempt proceedings. I also understand that no Final Decree or Order will be filed until I pay my assessed costs. Signature/Date American LegalNet, Inc. www.FormsWorkFlow.com