(  )

(Identify party(ies)) failed to provide a copy of a statement of issues to the mediator and the other parties (or to the mediator or to party(ies)).

(  )

(Identify plaintiff) failed to provide a copy of the pleadings to the mediator.

(  )

(Identify party(ies)) failed to attend within the first 30 minutes of a scheduled mediation session.

(Date)

(Name, address, telephone number and fax number, if any, of mediator)