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(To be completed by SMDRA) Request Received:________________ CASE NO.___________
South Metro Denver REALTOR® Association MEDIATION PROGRAM INTAKE FORM(Please
print legibly - All information must be completed or the form cannot
be processed. One party
Party Calling To Initiate Mediation: ____________________________________________
Property Address: _____________________________________________
Amount of Dispute: _____________________________________________
Type of Dispute: _____________________________________________
Information on Parties:
Buyer(s): Name______________________________________________________
Mailing Address______________________________________________
City/State/Zip________________________________________________
Phone______________________________________________________
Buyer’s Agent: Name______________________________________________________
Company Name______________________________________________
Mailing Address_____________________________________________
City/State/Zip_______________________________________________
Phone_____________________________________________________
Seller(s): Name______________________________________________________
Mailing Address_____________________________________________
City/State/Zip_______________________________________________
Phone_____________________________________________________
Listing Agent: Name______________________________________________________
Company Name______________________________________________
Mailing Address_____________________________________________
City/State/Zip_______________________________________________
Phone_____________________________________________________
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