COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

DISPUTE RESOLUTION DEPARTMENT

HAMILTON COUNTY, OHIO

ANNUAL MEDIATOR COMPLIANCE STATEMENT

Name:

Date Approved for the Mediator Appointment List:

Attached to this statement is proof of attendance of at least three hours of continuing education relating to children that has been approved by the Supreme Court of Ohio and if applicable, any other relevant training.

By signature below, I certify that I am unaware of any circumstances that would disqualify me from serving as a mediator in any court. I also certify that I have provided an updated resume to the Dispute Resolution Department with any substantive changes or any changes to name, address, telephone number and electronic mail address.

I understand that the Compliance Statement is due to the Dispute Resolution Department before the first of the year.

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Signature

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Date

Date Submitted to the Dispute Resolution Department: