About Us
Services
Mediation
Restorative Conferencing
Conflict Coaching
Facilitation
Training
Make a Payment
Programs
Landlord & Tenant
Community Conversations
Leadership
Staff/Board
Our Team
Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
Menu
About Us
Services
Mediation
Restorative Conferencing
Conflict Coaching
Facilitation
Training
Make a Payment
Programs
Landlord & Tenant
Community Conversations
Leadership
Staff/Board
Our Team
Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
Search
Close this search box.
Donate
About Us
Services
Mediation
Restorative Conferencing
Conflict Coaching
Facilitation
Training
Make a Payment
Programs
Landlord & Tenant
Community Conversations
Leadership
Staff/Board
Our Team
Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
Menu
About Us
Services
Mediation
Restorative Conferencing
Conflict Coaching
Facilitation
Training
Make a Payment
Programs
Landlord & Tenant
Community Conversations
Leadership
Staff/Board
Our Team
Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
Search
Close this search box.
Donate
Apply for Free/ Reduced Fees
Income Survey
Income Survey
Fees for mediation are split evenly between the parties, unless you have made a mutual decision together to alter this arrangement. If you believe mediation will be of assistance to you but don’t feel you can afford the process, we offer our services on a sliding scale based on federal poverty guidelines. Please submit the forms below and remit the $25 administrative fee.
1. HOUSEHOLD INFORMATION
Beginning with yourself, list all people living with you for whom you are responsible or with whom you share food and household expenses regardless of age or relationship to you. Include the gross income* of every person over 18 years of age with whom you share household expenses.
Full Name
*
First Name, Last Name
Date of Birth:
*
Relationship to You:
*
Husband, daughter, etc...
Gross Monthly Salary: $
*
----------------------------------------------------------------------------------------------------------------------------------
Full Name
First Name, Last Name
Date of Birth:
Relationship to You:
Husband, daughter, etc...
Gross Monthly Salary: $
----------------------------------------------------------------------------------------------------------------------------------
Full Name
First Name, Last Name
Date of Birth:
Relationship to You:
Husband, daughter, etc...
Gross Monthly Salary: $
----------------------------------------------------------------------------------------------------------------------------------
Full Name
First Name, Last Name
Date of Birth:
Relationship to You:
Husband, daughter, etc...
Gross Monthly Salary: $
----------------------------------------------------------------------------------------------------------------------------------
Full Name
First Name, Last Name
Date of Birth:
Relationship to You:
Husband, daughter, etc...
Gross Monthly Salary: $
----------------------------------------------------------------------------------------------------------------------------------
2. Financial Information
A. Employment
Employer:
*
Starting Date:
Phone Number
Hourly Wages: $
Hours/Weeks:
Type of Work:
Gross Monthly Income: $
B. Other Income
(Enter amounts for applicable options)
Alimony: $
Child Support: $
Disability Benefits: $
Rental Income: $
Social Security: $
Unemployment Comp: $
Retirement/Pension: $
C. Deductions
Alimony: $
Child Support: $
STATEMENT OF VERIFICATION
I verify, under penalties of perjury, that the information given above is true and correct and that, if any of this information changes after submitting this form, I will inform Mountain Mediation Center.
Signature
Clear
Printed Name
Today's Date
If you are human, leave this field blank.
Submit
Δ
Translate »