IN THE SUPERIOR COURT OF__________________ COUNTY, GEORGIA

ALTERNATIVE DISPUTE RESOLUTION PROGRAM

SOUTHERN JUDICIAL CIRCUIT

VOUCHER FOR COMPENSATION OF ASSIGNED NEUTRAL

________________________________
PLAINTIFF

CIVIL ACTION FILE NO. ___________________

________________________________
DEFENDANT

NEUTRAL'S CERTIFICATION

I certify that a Alternative Dispute Resolution, ("ADR"), session was conducted with the parties named above on ____________________________________________________, with the following results:

___________ A full agreement

___________ No agreement

___________ Other

Request is hereby made for compensation in the amount of $__________________ for ADR services rendered.
 

                                                                                           (1) Time spent in mediation:                                      

                                                                                           (2) Time spent in preparation:                                   
                                       
                                                                                           (3) Expenses:                                                              
                                                                                                 (Attach detailed statement)
 

____________________________________________________
Neutral's Signature

____________________________________________________
Printed or Typed Name

____________________________________________________
P.O. Box or Street Address

____________________________________________________
City, State, and Zip Code

AUTHORIZATION FOR PAYMENT

Approved for payment in the amount of $______________ to the above-named Neutral.

This _______ day of ________________________________ , 20_____.

                                                        ___________________________________________
                                                        Tim C. Hendrick
                                                        Administrator, Alternative Dispute Resolution Program
                                                        Southern Judicial Circuit
                                                        Post Office Box 2227   
                                                        Moultrie, Georgia 31776-2227
                                                        Telephone: (229) 890-5624



                                                                                                
County

                                                                                             
File Name

                                                                                             
Civil Action File No.