Verified Statement Of Bankruptcy Mediator Template

							 1   [Name and Address]

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     Attorneys for
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 4                                 UNITED STATES BANKRUPTCY COURT
 5                               IN AND FOR THE DISTRICT OF ARIZONA
 6    In re:                                             CHAPTER _ PROCEEDING

 7                             ,                         Case No.

 8                     Debtor.

 9                               ,                       ADV. NO.
10                     Plaintiff,                        VERIFIED STATEMENT OF __________
                                                         IN SUPPORT OF APPLICATION TO
11    vs.                                                EMPLOY MEDIATOR
12                                 ,
13                     Defendant.
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     STATE OF ARIZONA   )
15                      ) ss.
     COUNTY OF MARICOPA )
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               _______________, being first duly sworn upon [his][her] oath, deposes and states:
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               1.     I am an attorney duly admitted to practice in the State of Arizona, and before the
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     United States Bankruptcy Court.
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               2.     I    maintain    a   law    practice    located    at   ____________________,
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     ____________________, Phoenix, AZ __________. I make this declaration based upon my
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     personal knowledge in support of the Application To Employ Mediator filed in the above-
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     captioned adversary proceeding No. __________ (“Adversary Proceeding”).
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               3.     _______________ and _______________ who are the parties to the Adversary
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     Proceeding (the “Parties”) seek to employ me to act as a mediator for the Adversary Proceeding
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     pursuant to Local Bankruptcy Rule 9072-7.
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               4.     I have considerable experience in mediation having previously served as
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     mediator in several other similar matters.
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 1             5.       I have been a member of the State Bar of Arizona since __________, and believe

 2   that I am qualified to serve as the mediator for the Adversary Proceeding.

 3             6.       I do not hold, nor represent, an interest adverse to the Debtor, the Parties to the

 4   Adversary Proceeding nor the Debtor’s bankruptcy estate.

 5             7.       To the best of my knowledge and belief, I have no connection with the Debtor,

 6   the Parties to the Adversary Proceeding, the Debtor’s bankruptcy estate nor their respective

 7   attorneys.

 8             8.       The only agreement between myself and the Parties to the Adversary Proceeding

 9   for payment of my fees and expenses is that I shall be compensated hourly at the rate of $_____

10   per hour, that each of the Parties shall pay one-half (1/2) of my fees and expenses and that I

11   shall be remitted a retainer in the amount of $_________ by each of the Parties to be paid prior

12   to the commencement of the mediation.

13             9.       I agree to accept employment on the terms and conditions set forth in the

14   Application.

15             10.      I have not shared, nor agreed to share, any fees or expenses which I may earn as

16   a result of my employment as the mediator for the Adversary Proceeding. Similarly, I have

17   received no payment and have entered into no agreement regarding payment except as disclosed

18   herein.

19             11.      I will maintain time records for my time spent on this mediation. [Additionally, I

20   agree to submit a fee application to the Bankruptcy Court for approval regarding any of my fees

21   and expenses to be paid by the bankruptcy estate.]

22             Dated:         _____, 200_.

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                        _______________________________________
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25             SUBSCRIBED AND SWORN to before me this date: ____, 200 , by                              .
                                          _________________________________
26                                        Notary Public
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     My Commission Expires: _______________________
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                                                        -2-
 1   COPIES of the foregoing mailed on
     __________, 200__ to:
 2
     United States Trustee
 3   230 North First Avenue, Suite 204
     Phoenix, AZ 85003-1706
 4
     [Name and Address]
 5   Attorney for the Debtor

 6   [Name and address]
     Chapter 7 Trustee
 7
     [Name and Address]
 8   Proposed Mediator

 9   [Name and Address]
     Attorney for the Plaintiff
10
     [Name and Address]
11   Attorney for the Defendant

12   By____________________

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                                         -3-