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DISTRICT OF COLUMBIA COURT OF APPEALS
MEDIATION SCREENING STATEMENT
(Civil, Family & Probate appeals)
Appeal No._____________________ Superior Ct. No._________________
1. Case caption:__________________________________________________
2. Case type:_____________________________________________________
3. Brief description of the facts that gave rise to the initial dispute:__________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_____________________________________________________________
4. Nature of disposition below:______________________________________
_______________________________________________________________________________________________________________________________________________________________________________________
5. State concisely the principal issue(s) in this appeal and the standard of review governing each:__________________________________________
_____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________
6. If this appeal presents a new question of law, state the issue:_____________
_______________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________
7. Factors weighing in favor of or against mediation:_____________________ _____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8. Describe any attempts to negotiate a resolution of this dispute since the decision being appealed was entered by the trial court:__________________ _______________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________
9. Name and phone number of opposing counsel:________________________
_______________________________________________________________________________________________________________________________________________________________________________________
I certify that the above information is accurate to the best of my knowledge, and a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the person(s) listed below on {date} ________________________________________
Name: ________________________________________
Address: ______________________________________
City, State, Zip: ________________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
______________________________ ______________________________
Signature Name
______________________________ ______________________________
Bar No. Address
______________________________ ______________________________
Telephone Number Email Address
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