Support Income Statement

Please do not begin this form until you have your documentation prepared to send. This should include, at a minumum, any tax return or pay stubs which are required to verify monthly gross income.

Name

First Name

Last Name

What is your monthly GROSS income?

Are you currently married to someone other than the person listed this case?

If so, does your spouse have any additional children who reside in your home?

Have you been ordered to pay spousal support by any court?

If so, how much?

Have you been ordered to pay child support by any court for any other children?

If so, how much?

Does your child attend daycare while you are at work?

If so, how much?

Do you maintain health insurance on your child?

If so, how much?

If so, please provide the following below: Provider, Policy Name, Name of Policy Holder, and Policy Number.

By pressing submit below and submitting this information, I verify that all information provided is true and accurate to the best of my knowledge and I have attempted to ensure that a complete statement has been provided:

This is for support cases. Please note documents required in this submission.

Asset and Income Statement

Name

First Name

Last Name

The financial information on the following pages is important. If you need help in completing any item, please let the Scheler Mediation Services, LLC know. Please email copies of this information for everyone in the mediation, along with documentation for the items on the sheet (i.e., bank statement, appraisals, etc.). Please also email copies of Federal and State income Tax returns for the past two years.

Understood

Real Estate Market Value

Real Estate Debt (Mortgage, Equity Loan(s), Etc.)

Total Real Estate Value

Checking and Savings Accounts

Notes, Savings Bonds, Etc

Stocks, Bonds, Mutual Funds

Life Insurance

Business or Professional Interests

Miscellaneous Assets

Personal Effects, Automobiles, Tangible Personal Property (valued at $500 or more)

Pension plans, Keogh, IRAs or Profit Sharing Plans

Liabilities

Monthly Gross Salary

Dividend Income

Interest Income

Rental Income

Other Income Not Previously Listed

Child Care Cost Per Month

Health Insurance Cost Per Month

Court Ordered or Formally Agreed To Support for other children

Court Ordered or Formally agreed to Support for former spouse

By submitting the above document I affirm that I have reviewed all information and answers and have provided answers with all due diligence and to the best of my ability and knowledge. I understand that should I find that I have erred in any answer or find additional information which pertains to any category in the above, I may submit that data to all parties via email within 48 hours of the date of mediation.

Affirm

This is for clients who are seeking a separation agreement. Please note that other documents may be required in addition to this submission.

This is for self-pay clients. Please complete this only when instructed to by a mediator or staff.

Fee Amendment

We the undersigned parties, having agreed to voluntarily enter the mediation process, understand, and consent to the following: 1. Fees: Fees will be defined as followed: a. Standard Fees will apply. Standard fees for mediation include:

Basic Mediation Services: $120 an hour for the first hour or any portion thereof. Following the first hour, the fee will be billed at an increment of 1/6th an hour (or every ten minutes) or any portion thereof. (in example, should a mediation require an hour and ten minutes to conclude a mediation and produce an agreement, the charge would be $140.00). Marital/Separation/Divorce Mediation Services: $150 an hour for the first hour or any portion thereof. Following the first hour, the fee will be billed at an increment of 1/6th an hour (or every ten minutes) or any portion thereof. (in example, should a mediation require an hour and ten minutes to conclude a mediation and produce an agreement, the charge would be $175.00). Workplace Mediation Services: $240 an hour for the first hour or any portion thereof. Following the first hour, the fee will be billed at an increment of 1/6th an hour (or every ten minutes) or any portion thereof. (in example, should a mediation require an hour and ten minutes to conclude a mediation and produce an agreement, the charge would be $280.00). Additionally, any time spent traveling to and from any location required for in person services, such as signature requirements for mediations held virtually or parties that desire the mediator to file for the parties, will require charges for time at the above rate.

Mailing: Should any documents require mailing, beyond standard first class postage in a standard envelope (example given: next day, oversize, UPS, FEDEX, etc) will be charged to the party requesting such delivery.

Scheduling: To reserve the date of mediation, the parties agree that they shall pay a non-refundable fee of $60 which is due upon scheduling. This amount will be applied to the total amount due the date of mediation. Should a subsequent session be required, the parties understand that for each subsequent session shall require such non-refundable fee and shall so be applied to any balance due for that subsequent mediation session.

These changes are the only changes to the Agreement to Mediate. The entire remainder of the original Agreement to Mediate remains in full force. This Amendment shall be effective once signed by both parties.

The parties agree that, should the parties breach this fee amendment, they shall be responsible for the costs of all litigation to recover said fees, to include interest on said fees at 8% per annum, compounded, the hourly rate consistent with the type of mediation indicated above, an hour, for all time spent litigating or attending any ADR in the matter, the cost for any counsel incurred by Scheler Mediation Services, LLC and any other costs, fees, or awards incurred or recovered by Scheler Mediation Services, LLC.

By Selecting Agree and Including My Name and Unique Identifier Below, I Understand That This Has The Same Effect as a Physical Signature and is an Irrevocable agreement.

SIGNED

Unique Identifier

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