CIRCUIT COURT FOR MONTGOMERY COUNTY
CONFIDENTIAL ALTERNATIVE DISPUTE RESOLUTION (ADR) STATEMENT
Instruction: Please complete and return this form to the MEDIATOR. Do not provide copy to the Court or
Nature of the Case: A brief statement of the facts.
2. Claims and/or Defenses: Each party to provide claims and defenses as asserted by that party. For personal
injury cases, indicate if liability and/or medical necessity and/or reasonableness of bills are issues.
3. Relief Sought: Specify nature and amount of each item of damage claimed or description of equitable
relief sought. Is permanency an issue? If so, what is the rating?
4. Is any settlement subject to a lien? Indicate which expenses have already been paid and by whom?
5. Most recent settlement demand/offer.
6. What figure do you believe would settle this case?