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Office of the City Attorney
City Hall
300 South Adams Street
Tallahassee, FL 32301
850-891-8554

For more information on this mediation program, please visit the Landlord-Tenant Mediation Program information page.

Landlord-Tenant Mediation Program Referral Form ( indicates required field)*
Source of Referral (Agency): or Self Referred (Party#1 Name): * (You must fill in one field or the other)
Date of Referral: * (ex. MM/DD/YYYY)
Reason for Referral/ Matter Referred: *

Party Referred #1:
Has mediation been discussed with this party? *	Yes No
Name: *
Street Address: *
City/Zip: *
Telephone: * (ex. ###-###-####)
Fax: (ex. ###-###-####)
Email:

Party Referred #2:
Has mediation been discussed with this party? *	Yes No
Name: *
Street Address: *
City/Zip: *
Telephone: * (ex. ###-###-####)
Fax: (ex. ###-###-####)
Email:
Please list additional parties, if any.
Special Needs/ Circumstances/ Time and Day Availability:

Agency Referral Prepared By:
Name:
Telephone: (ex. ###-###-####)
Fax: (ex. ###-###-####)
Email:
Shall we call you regarding the disposition of this matter? * Yes No

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