Form 5

IN THE SUPREME COURT OF THE STATE OF MONTANA

Supreme Court Cause No.__________

_________________________________,

Plaintiff/Petitioner and

☐ Appellant or ☐ Appellee,

v.SELECTION OF MEDIATOR    

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Defendant/Respondent and

☐ Appellant or ☐ Appellee.

COME NOW the parties and advise that they have stipulated to and selected __________________________ as mediator for purposes of complying with the requirements of M. R. App. P. 7(4)(c).

Dated this ___ day of __________, 20___.

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Attorney for Appellant

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Attorney for Appellee