Request for Mediation

Please complete the following form if you are interested in having your case mediated through the FINRA Dispute Resolution Mediation Program. You may file a Request for Mediation at any time, whether or not you have already filed an arbitration claim.

When we receive your Request, the FINRA Dispute Resolution staff will contact the other party or parties to the dispute to explain the mediation process, and seek their agreement to mediate. We may provide the other parties to the dispute with a copy of your completed Request for Mediation Form. However, mediation is a voluntary process, and no party is required to mediate a dispute.

To complete this form, please fill in the areas as indicated below, and press the submit button to get the information to us.

Please do not submit any fees at this time. FINRA will send you an invoice for the required fees only after all parties agree to mediate.

Note that filing a Request for Mediation is not a substitute for filing a Statement of Claim in arbitration. In order to file an arbitration claim, you must follow the procedures in FINRA's Uniform Forms Guide.
Prefix First Name Middle Name Last Name




Street Address
City State Zip
Telephone
Fax
E-Mail Address    Please enter only one e-mail address.
Securities Account Number(s) (last 4 digits only) (If this case involves one or more securities accounts)
Check here if you are: a) represented by an attorney or b) an attorney representing the person requesting mediation. If this box is checked, provide the attorney's name, address and phone number in the space below.
Attorney Contact Information:

1. I request that my dispute be mediated by FINRA Dispute Resolution under the FINRA Dispute Resolution Mediation Rules. I request that FINRA Dispute Resolution contact the other party(s) and seek their agreement to mediate. I ask that the mediation be held in the city of .

Note: A mediation can be held in any FINRA hearing location, or in another location mutually agreed upon by the parties and the mediator.

2. Please Check One:
  This dispute involves a pending FINRA arbitration case. The arbitration case is currently assigned to the regional office located in (city). The case number is .

  This dispute does not involve a pending FINRA arbitration case.

3. Check here if you have previously notified the other party or parties to the dispute that you have a complaint. If this box is checked, provide as much information as possible about your complaint (e.g., when you made your complaint, the names of the persons you contacted, and whether you made or complaint in person or by phone, letter or e-mail.)


4.   Please provide a description of the dispute. Include a detailed summary of what occurred, the names, account numbers (last 4 digits only), and location of any securities account(s) at issue, the date(s) on which the dispute occurred, and the names and titles of all individuals involved. Use the space below to forward your information.


5.   What relief are you requesting? If monetary damages, please list the monetary damages you seek. If you seek non-monetary relief, please describe the relief you seek.


6.   Please provide the following contact information for all parties to the dispute. If you list a brokerage firm, provide the name of a contact person at the brokerage firm who would have the most information about the dispute.

Name of Party
Firm
Contact Person
Prefix First Name Middle Name Last Name
Position/Title:
Street Address
City State Zip
Telephone
Fax
E-Mail Address

Use this space to provide information for additional parties to the dispute. Please include the same information as above.


Your Request for Mediation will be forwarded to a Mediation Administrator
at the Dispute Resolution Office nearest to you.