Environmental Mediation Center - Mediator Invoice Form

This invoice form applies to all 3 programs (VTAMP, HIAMP, and NHAMP)

Mediating Program: * Mediating Program:

Name of Dispute: *

Date services were rendered: *

Mediation Details / Payments

Preparation time:

In Hours

Mediation Time:

In Hours

Travel time:

In Hours

Mileage Traveled:

Total Fee to be paid to the mediator: $

Prep and Mediator time bill at $240/hour with $90/hour donation = $150/hour paid

Mileage Reimbursement Total: $

Miles * $.50/mile

Mediation services provided by: *

Mediator's Social Security Number: *

Mediator's Address: *

I certify that the above invoice is accurate: *

By typing your name above and submitting this form you certify the above invoice is accurate.

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