Jefferson County Association of REALTORS®
MEDIATION PROGRAM INTAKE FORM


Date: __________________


Party Initiating Mediation: ______________________________________________
Property Address:
______________________________________________

Amount of Dispute:
______________________________________________

Type of Dispute:
______________________________________________


Information on Parties:

Buyer(s): Name______________________________________________________
 
Address____________________________________________________
 
Address____________________________________________________
 
Phone/Fax__________________________________________________
   
Buyer's Agent:
Name______________________________________________________
 
Company Name______________________________________________
 
Address____________________________________________________
 
Address____________________________________________________
 
Phone/Fax__________________________________________________
   

Seller(s):
Name______________________________________________________
 
Address____________________________________________________
 
Address____________________________________________________
  Phone/Fax__________________________________________________
   

Listing Agent:
Name______________________________________________________
 
Company Name______________________________________________
 
Address____________________________________________________
 
Address____________________________________________________
 
Phone/Fax__________________________________________________
   


FOR JCAR USE ONLY:

Case No.:__________ Date Packet Mailed to Parties:__________ Form to Mediation Provider:_________