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EXHIBIT A
SAMPLE MOTION FOR APPOINTMENT
OF PROGRAM ATTORNEY
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IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
Case No.
)
)
)
Plaintiff(s), ) MOTION FOR APPOINTMENT
) OF PROGRAM ATTORNEY
v. )
)
)
Defendant(s). )
Pursuant to the Pro Se Settlement Assistance Program of the Western District of North
Carolina (“Program”), and respectfully request that
be appointed as settlement counsel for in the above-
referenced matter and that an Order for Referral to the Pro Se Settlement Assistance Program be
entered. In support of this Motion, and show as follows:
1. has been advised of the Program and has voluntarily elected to
participate in the Program.
2. has been contacted by the Clerk and has agreed to serve in the
capacity of settlement counsel for the Pro Se Litigant in this matter pursuant to the
Program guidelines.
3. will not enter into any fee collection agreement or otherwise seek
compensation from for the performance of this limited representation.
4. hereby acknowledges and agrees that will
provide only limited representation as contemplated by the Program, and will have no
other duties or responsibilities with respect to the representation of the
in this matter. Specifically, will provide representation in connection
with settlement proceedings in this case only and has no obligation to conduct any
discovery, to prepare or respond to any motions, or to appear for at the
trial of this case.
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5. also acknowledges that he/she will be required to pay a portion of
the costs of mediation, including the mediator’s fee, unless the Court determines that
is indigent or has reached some other agreement with the other party or
parties to his/her case regarding payment of these costs.
6. With the appointment of by the Court, the case will be ready to
proceed through the Program.
WHEREFORE, and respectfully request that the Court
enter an Order appointing to represent solely for the limited
purpose of assisting said party in connection with settlement proceedings in this case with no
obligation to conduct any discovery, to prepare or respond to any motions or for the trial of this
case and ordering a settlement conference pursuant to the Program. and
also request that representation terminate following
the completion of the Settlement Conference if an impasse is reported, or if settled, upon
submission of settlement documents and the closing of the case file.
Respectfully submitted, this day of , 20 .
________________________________ s/
Pro Se Litigant NC Bar #
Phone #
Email:
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EXHIBIT B
SAMPLE MEDIATOR’S REPORT
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IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
Case No. [######]
)
)
Plaintiff(s), )
) MEDIATOR’S REPORT OF
v. ) SETTLEMENT CONFERENCE
) PURSUANT TO PRO SE
) SETTLEMENT ASSISTANCE
) PROGRAM
Defendant(s). )
)
On ___________________, the parties, their counsel, and the undersigned held a
mediated settlement conference pursuant to this Court’s Order dated ________________
and the Pro Se Settlement Assistance Program. The results of the mediated settlement
conference were as follows:
□ An agreement was reached on all issues. The Court file will be closed by
the filing of a notice/stipulation of dismissal within thirty (30) days.
Counsel for Plaintiff(s)/Defendant(s) shall be responsible for filing said
dismissal. The representation of Plaintiff(s)/Defendant(s) by Program
Counsel shall terminate upon the filing of such dismissal or thirty (30) days
from the date of the settlement conference, whichever first occurs.
□ The parties reached agreement on the following issues:
The representation of Plaintiff(s)/Defendant(s) by Program Counsel is
hereby terminated pursuant to the Court’s Order.
□ The parties were unable to reach agreement on any issues and an impasse
was declared. The representation of Plaintiff(s)/Defendant(s) by Program
Counsel is hereby terminated pursuant to the Court’s Order.
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All mediator fees have been paid or waived.
Reported this __________ day of __________________, 20____.
List of Attendees: Mediator:
2
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CERTIFICATE OF SERVICE
I certify that on this _________ day of _________________, 20____, this report
was served by U.S. Mail and/or the ECF electronic notification system for registered
users to the attorney(s) of record as listed below:
[Mediator Name and Address]
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