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Write the outcomes you would like from this mediation: <br /> (This information will be shared with all parties in order for everyone to have a good understanding of <br /> why mediation is needed.) <br /> Please check and sign here if'you do not want your desired outcomes shared with the other party. <br /> Sign here: <br /> ................................................................................................................................................................................................ <br /> Mediation Services for Anoka County is a community focused 501(c)(3) nonprofit organization <br /> funded by private organizations and occasionally by the county and state. <br /> Our funders request that we provide the following information. <br /> Gender: Male Female Decline <br /> Age: Under 18 18-2.2 23-54 55-64 65-74 75-84 Decline <br /> Ethnic Group: <br /> African American American Indian Asian/SE Asian/Pacific Islanders <br /> Caucasian/White Hispanic/Chicano/Latina Multi-Racial <br /> ether: Dedine <br /> Income: Under$20,000 $20,001 - $40,000 Over$40,001 Decline <br /> Mediation Services for Anoka County is a community-focused 501(c)(3) non-profit organization located at <br /> 2520 Coon Rapids Blvd. Suite 100 Coon Rapids, MN 55433 <br /> www.mediationservice.org office: 763-422-8878 fax: 763-422-0808 info@mediationservice.org <br /> 101 <br />