APPENDIX 3
Statement of Independence

I, _______, the Mediator in the dispute between ______ and _________ will perform duties in this Mediation process pursuant to the Code of Conduct for Mediators. I have responsibilities to the parties that include, but are not limited to, honoring their right of self-determination; acting with impartiality; and avoiding coercion, improper influence, and conflicts of interest. I will also maintain an appropriate demeanor in the Mediation process, preserve confidentiality, and promote the awareness by the parties of the interests of non-participating persons. Throughout this Mediation process I will act only with principles of fairness, integrity and impartiality. I will act only according to the needs and interests of the parties and not my own. None of my actions will be performed with impropriety nor with the appearance of impropriety.

I hereby disclose the nature of all contacts, business or personal, that I have had with any of the parties, or persons connected with the parties, to this Mediation:

I hereby disclose the following actual conflicts of interest:

I hereby disclose the following potential conflicts of interest:

I hereby disclose the following all other reasons why my impartiality, neutrality, or independence might be affected during and after this Mediation:

I hereby state, after reasonable inquiry and search, that there is no reason or basis for an actual or potential conflict of interest or other fact or circumstance that would disqualify me from serving as Mediator in the subject dispute. [ _____] Check box if applicable.

From the time of my appointment as Mediator and throughout the Mediation proceedings and process, I shall without delay disclose to the parties in a written Supplemental Statement of Independence any additional or new, actual or potential conflicts of interest or reasons why my impartiality, neutrality, or independence might be affected during and after this Mediation, unless the parties have already been informed of them in writing by the Mediator.

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Mediator Signature

Name and address and contact information: