Form 5 
 IN THE SUPREME COURT OF THE STATE OF MONTANA 
 Supreme Court Cause No.__________ 
 _________________________________, 
 Plaintiff/Petitioner and 
 ☐ Appellant or ☐ Appellee, 
 v.SELECTION OF MEDIATOR     
 _________________________________, 
 Defendant/Respondent and 
 ☐ Appellant or ☐ Appellee. 
 COME NOW the parties and advise that they have stipulated to and selected __________________________ as mediator for purposes of complying with the requirements of M. R. App. P. 7(4)(c). 
 Dated this ___ day of __________, 20___. 
 __________________________________ 
 Attorney for Appellant 
 __________________________________ 
 Attorney for Appellee