12th Circuit Foreclosure Mediation Participation Form {Form H}

FORM "H" Revised 5/31/16 12th CIRCUIT FORECLOSURE MEDIATION PARTICIPATION FORM Plaintiff's Counsel Shall Provide Form to Program Manager at Conclusion of Mediation DATE OF MEDIATION:___________________ CASE NUMBER:_____________________ OFFICE MANAGER_________________________ If a party representative does not have full authority to settle without further consultation, the Mediation Program will report to the court that the party failed to appear for mediation. Any representative appearing by telephone must remain on the telephone during the entire mediation session. Communications in mediation are confidential and privileged to the extent provided by the Florida Mediation Confidentiality and Privilege Act (F.S. 44.401 ­ 44.406) and some exceptions to confidentiality and privilege exist under the law. This form and related party/attorney communications with the program manager are not confidential or privileged. Plaintiff's Attorney: ____________________________________________________________/______________________________ (printed last name) Plaintiff's Representative: _______________________________________________________/______________________________ (printed last name) __________________________________________________________________________________________ The plaintiff representative has full authority to settle without further consultation including, but not limited to, authority to approve loan modifications, consent to borrower refinancing or short sales, to authorize deed in lieu of foreclosure, consent to waiver of deficiencies and consent to other workout options. _____ Yes ____ No The plaintiff representative's name is listed on the Form A filed with the Court. _____ Yes ____ No The plaintiff representative received the borrower documentation at least 30 days in advance of mediation and reviewed said documentation prior to mediation. _____ Yes ____ No ________________________________________/______________________________ [Signature of Representative or Counsel] [printed last name] Defendant's Attorney: _______________________________________________________ /_________________________________ (printed last name) Defendant: _______________________________________________________________/__________________________________ (printed last name) Defendant: ______________________________________________________________ /__________________________________ (printed last name) The borrower timely received the Plaintiff's disclosure in advance of mediation. _____Yes ____No Borrower's Signature_____________________________________________ Others Borrowers and Defendants named in court proceeding but not present: _________________________________________________________________________/___________________________________ (printed last name) _________________________________________________________________________/___________________________________ (printed last name) Persons present at the mediation but not named in the court proceedings: ________________________________________________________________ ________/____________________________________ (printed last name) ________________________________________________________________________/____________________________________ (printed last name) Name of Mediator: ________________________________ Signature ______________________________ (print mediator's full name) Program Mediator Outside Mediator USF Conflict Resolution CollaborativeMy Florida Mediator American LegalNet, Inc. www.FormsWorkFlow.com Residential Mortgage Mediation Program 6151 Lake Osprey Drive, Suite 300, Sarasota, FL 34240-84055804 Lakewood Ranch Blvd, N., Sarasota, FL 34240