Home Buyers/Home Sellers

Dispute Resolution System Request to initiate

 

MEDIATION – TRANSMITTAL FORM

 

(To be completed and mailed to:  Greater Allegheny Kiski Area Board of REALTORS Inc.,

PO Box 235, Natrona Heights, PA  15065, by party requesting mediation)

 

                                                                                                            DATE______________

  1. NAMES OF ALL PARTIES TO THE DISPUTE

_______________________________________________________________________

 

 

  1. PARTY REQUESTING MEDIATION

Name_______________________ Phone No. _____________FAX_________________

 

Address________________________________________________________________

 Buyer           Seller         Agent for Seller

       Subagent for Seller           Agent for Buyer

       Builder/contractor             Other __________________________________________

 

     Professional Liability Insurance Company: ____________________________________

 

     Name and Address of Legal Counsel or Other Representative:

     Name __________________________ Phone No. ______________________________

     Firm ________________________________FAX ______________________________

     Address ________________________________________________________________

 

  1. OTHER PARTIES

Name _______________________ Phone No. _____________ FAX ______________

Address ______________________________________________________________

 Buyer           Seller         Agent for Seller

       Subagent for Seller           Agent for Buyer

      Builder/contractor             Other __________________________________________

Insurance Company: ___________________________________________________

Name and Address of Legal Counsel or Other Representative:

Name ________________________ Phone No. ______________________________

Firm _________________________________ FAX __________________________

Address _____________________________________________________________

 

Name _______________________ Phone No. _____________ FAX ______________

Address ______________________________________________________________

 Buyer           Seller         Agent for Seller

       Subagent for Seller           Agent for Buyer

              Builder/contractor             Other __________________________________________

Insurance Company: ___________________________________________________

Name and Address of Legal Counsel or Other Representative:

Name ________________________ Phone No. ______________________________

Firm _________________________________ FAX __________________________

Address _____________________________________________________________

 

Name _______________________ Phone No. _____________ FAX ______________

Address ______________________________________________________________

 Buyer           Seller         Agent for Seller

       Subagent for Seller           Agent for Buyer

             Builder/contractor             Other __________________________________________

Insurance Company: ______________________________________________________

Name and Address of Legal Counsel or Other Representative:

Name ________________________ Phone No. ________________________________

Firm _________________________________ FAX ____________________________

Address _______________________________________________________________

 

  1. BRIEF DESCRIPTION OF CLAIM:

______________________________________________________________________

            ______________________________________________________________________

            ______________________________________________________________________

            ______________________________________________________________________

            ______________________________________________________________________

            ______________________________________________________________________

      ______________________________________________________________________

 

  1. AMOUNT OF MONEY INVOLVED:   _________________ ($ ________________)

 

  1. Have there been any formal court pleadings filed in this case?

 

 Yes          No

            If yes, are there any trial dates or time limitations involved?

            Date ____________________________ Court _______________________________

            County __________________________ Judge _______________________________

            Court Docket# _________________________

 

  1. Do you have authority to enter into and sign a binding written agreement to settle this on behalf of the party you represent?                 

 

 Yes          No

 

            Comment: ____________________________________________________________

 

  1. Has a prior agreement to mediate been signed by the parties?

 Yes          No

            If yes, please attach a copy of the signed agreement.

 

 

PLEASE MAIL THIS FORM TO THE DRS MEDIATION ADMINISTRATOR WHO IS IDENTIFIED BELOW TOGETHER WITH AS MANY COPIES AS THERE ARE PARTIES, PLUS ONE.

 

            Mediation Administrator:            Sharon Resek, Executive Officer

                                                            Greater Allegheny Kiski Area Board of REALTORS

                                                            P O Box 235

                                                            Natrona Heights, PA  15065-0235

                                                            724-226-8637

                                                            Fax 724-226-8647