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104 East Main Street · Post Office Box 2390 · Lancaster Ohio 43130-5390

Sherry L. Eckman
Clerk of Court

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   Mediation Intake Form

Basic Instructions for Completing Mediation Intake Form:

  1. Please complete the form to the best of your knowledge.

  2. Please leave the following area blank:  "Mediation No."

  3. Do not write on the form below the section labeled "Claimant's Statement."

  4. Please mail the completed form to:
             Fairfield County Municipal Court
             Attention:  Mediator
             104 E. Main Street
             Lancaster, Ohio 43130

  5. Upon the mediator receiving your document, he will contact you in order to discuss the
    issue(s) at hand and schedule any necessary mediation hearings.

  6. Mediation is held on Wednesday at noon in the jury trial room, located in the lower level (basement) of the City Building.

  7. The claimant is the person(s) who is claiming that a monetary or material item is owed to them, and they are the party and/or applicant(s) requesting mediation.

  8. The respondent(s) is the person(s) that the claimant is attempting to enter into an agreement in efforts to resolve the issue(s) at hand.

  9. As an alternative you may email  [email protected]  for online instructions.

The mediation intake form is available in either an Adobe .PFD or a Microsoft Word Document.     Please choose one of the links below:

Mediation Intake Form (Adobe .PDF)

Mediation Intake Form (Microsoft Word)


Also available is an explanation of mediation.  Please choose one of the links below:

What is Mediation? (Adobe .PDF)

What is Mediation? (Microsoft Word)


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