STATE OF NORTH CAROLINA
Notice of Mediation Impasse
Agency: _________________________________________________________ Complaint: _______________________________________________________ Name of Party #1: _________________________________________________ Name of Party #2: _________________________________________________
A resolution to the above dispute was not reached during the course of the mediation.
______________________________________________________________________ #1 Date
Party
______________________________________________________________________ #2 Date
Party
______________________________________________________________________ Mediator Date
______________________________________________________________________ Mediator Date
07/2006