Shulman ADR Law, P.A.

Mediation Payment Authorization

Please complete this form by the deadline in your Mediation Confirmation email.

Thank you for selecting Shulman ADR Law, P.A. for your upcoming mediation. We are happy to be of service. This form takes about three minutes. After you sign, you will be taken to a secure Stripe page to save a back-up card. Your card is not charged today.

Mediation details

Date of mediation conference Parties to dispute (e.g., “Smith v. Jones”)

Name of person completing form

Role

Which side are you paying for?

Attorney or law firm (if any)

How you intend to pay

I agree to pay, in full, my portion of the charges by

Whichever method you choose, a valid credit or debit card is required as a back-up. You will enter it on the next screen, a secure page hosted by Stripe (PCI DSS Level 1). Shulman ADR Law, P.A. never sees your full card number.

Authorization

Per the Mediation Confirmation provided to me (or to my counsel, if any), payment is due at the conclusion of the mediation session (or upon late cancellation or late postponement), unless prior arrangements have been made. The total amount due, as evidenced by invoice(s) Shulman ADR Law, P.A. shall send, shall equal my portion of the total mediation fees, not less than my share of the minimum engagement fees listed on either https://shulmanadrlaw.com/mediation-fees or the mediation confirmation notice.

I understand my portion of the mediation fees is due at the conclusion of the mediation session or upon late cancellation or late postponement of the mediation. I agree to pay, in full, my portion of the charges by the following method: [the method selected above].

Regardless of the method selected, I understand I still must provide a valid credit or debit card, to be charged if payment is not received within 15 calendar days from the date of the invoice. I will enter the card on a secure page hosted by Stripe, a PCI DSS Level 1 certified payment processor; Shulman ADR Law, P.A. does not see or store my full card number.

By signing below, I specifically represent I am an authorized user of the card I provide on the Stripe page that follows this form, and I authorize Shulman ADR Law, P.A. to charge that credit/debit card a One Time Charge for my portion of the mediation charges incurred (as evidenced by the invoice sent to me or my counsel). I authorize such charge to be made either (a) immediately, if I have said above I wish to pay by such card, or (b) on or after the 16th calendar day after the invoice date, if payment by the selected alternate means has not been received. In the event payment is not received timely and the credit/debit card is declined, I agree to pay Shulman ADR Law, P.A., in addition to whatever else I may owe, its reasonable attorney's fees and costs of collection therewith.

Signature

Authorized user's name (as on the card)

Signature (type your full name)

Email address

Phone

I have read and agree to the authorization above. I intend my typed name to be my electronic signature, with the same effect as a handwritten signature. Date signed: .