REQUEST A MEDIATION Request a Mediation Salesforce Mediation Role ID Salesforce Contact ID Preface When did you learn about MediateArt? How did you learn about MediateArt? VLA Art Law Line VLA Website VLA Consultation Other Other: How did you learn about MediateArt? MediateArt provides a number of services. The staff reserves the right to assign a service based on your factual circumstances. Using the previous descriptions, which service(s) do you initially believe is suited to your circumstance? Please check all that apply Dispute Resolution (Mediation) Contract Negotiation Negotiation Counseling I'm unsure If you're unsure about what assistance you might need - please fill out and submit the About You section below and VLA-NY staff will reach out to assist you as soon as possible. About You I am responding as:An IndividualAn Organization Organization Name First Name Last Name Email Phone Address Line 1 Address Line 2 City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip/Postal Code Have you consulted an attorney?YesNo Are you represented by an attorney?YesNo What is your attorney's name? About the Second Party The other party is:An IndividualAn Organization Organization Name Their First Name Their Last Name Their Email Their Phone Their Address Line 1 Their Address Line 2 Their City Their StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Their Zip/Postal Code Have they consulted an attorney?YesNo Are they represented by an attorney?YesNo What is their attorney's name? Financial Information How did you file your taxes for 2022? Singly Jointly with a spouse Separately with a spouse I did not file for 2022 Adjusted Gross Income (usually line 32) Taxable Income (usually line 43) Household Gross Income Household Adjusted Gross Income Household Gross Income is typically found on line 22 Form 1040 and Household Adjusted Gross Income on line 32 Form 1040 For those filing separately, total Lines 22 for Household Gross Income and total lines 32 for Household Adjusted Gross Income. Number of dependents Arts Related? Yes No Incorporated? Yes No Tax-Exempt 501(c)(3) status?YesNo Annual Operating Budget Mediation Background Artistic DisciplineCraftsDanceDesignDigital ArtFashionFilmLiteraryMusicPhotographyContent CreatorTelevisionTheatreVisual ArtsOther/MultidisciplinaryUnknown Amount in Controversy (in Dollars) $ Please give a brief description of your situation below: When and how did you meet the second party? Are you and the second party still on speaking terms? When did you last speak or correspond with the second party? How frequently do you speak or correspond with the second party? Your relationship with the second party is currently:TerribleNot goodFairGoodExcellent Please provide any other information about your dispute or relationship with the second party that would give MediateArt a more complete understanding of your matter: reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Sign up to receive news & events from VLANY! first_nameJohnlast_nameSmithemailjohnsmith@example.comSubmit
