Caira by Unwildered can organize a small-claims file so the story is not buried inside screenshots.
Free Small Claims Mediation Statement Template
How to prepare a mediation summary that stays factual and settlement-focused. Use this page when you need a practical written record for the exact account, charge, notice or company process in front of you.
A do not pay stance can create fees, collections or account problems unless it is backed by the contract, the law or a written dispute route.
Public complaint patterns are useful, but they are not proof that a company did anything wrong in your case. Public settlement problems often arise when the amount, payment deadline, release wording and dismissal timing are not written down clearly.
Template
You can copy and paste this free download into Microsoft Word, then replace the bracketed prompts. No login is needed, and the wording is meant to work as an email or letter.
Copy-and-paste template
Small Claims Mediation Statement
To: [Name of other party, mediator, or court contact]
From: [Your full name]
Reference: [Case number, dispute reference, or subject]
Date: [Today's date]
Subject: Mediation Statement for [brief description of dispute, e.g., "unreturned security deposit," "unpaid invoice," etc.]Summary of Dispute:
On [date of incident or start of dispute], [briefly state what happened: e.g., "I paid $500 to [Company/Person] for [service/product], but the service was not provided as agreed."] I am seeking assistance to resolve this matter through mediation.Requested Outcome:
I am requesting [state your specific request: e.g., "a refund of $500," "completion of the contracted work," "payment of the outstanding invoice," etc.]. If this cannot be agreed upon, please provide the specific contract term, policy, or document that supports your position.Key Dates and Facts:
- [Date 1]: [Event or communication, e.g., "Deposit paid"]
- [Date 2]: [Event, e.g., "Service was scheduled to be completed"]
- [Date 3]: [Event, e.g., "Request for refund sent"]
Amount in Dispute: [$ amount]
Previous Contact: [Name, department, ticket number, phone/email, or other reference if any]Evidence Provided:
- [List attached or available documents, e.g., "Signed contract dated [date]," "Receipt for payment," "Text messages/emails regarding the dispute," "Photos of incomplete work," "Demand letter sent on [date]," "Court notice or proof of service," etc.]Preservation Request:
Please preserve all related communications, receipts, contracts, photos, and payment records until this matter is fully resolved.Next Steps:
Please respond in writing by [response deadline, e.g., "June 30, 2024" or "within 10 business days"] with either confirmation of the requested outcome or a written explanation and supporting documents if you disagree. If we cannot resolve this through mediation, I may proceed with the appropriate small claims or enforcement process, but I remain open to a written settlement.Sincerely,
[Your name]
[Your mailing address or email]
[Your phone number, if you wish to include it]
[Preferred contact method, if any]
What People Commonly Complain About Online
small-claims and contractor discussions often begin with a deposit paid, work not done, work done badly or a refund promised but not sent
court preparation usually fails when the claimant has screenshots but no exhibit order, no defendant legal name or no proof of service
settlement problems often arise when the parties agree by text but forget payment deadline, release wording and what happens if payment is missed
Example Scenarios
A customer prepares a mediation statement packet after a contractor refuses a refund and uses photos, texts and estimates as exhibits.
A defendant receives a claim and builds a timeline showing the goods were delivered, accepted and later damaged by someone else.
For this specific mediation statement issue, make the first example match your facts: who charged you, which account or document identifies the charge, what promise or term you rely on, and what outcome you want.
Specific Practical Note
Before sending, check the correct party name, amount, deadline, and strongest exhibit. A small-claims document should make the judge or other side see the contract, payment, photos, messages, and requested outcome in order.
What To Collect First
the contract, receipt, message or court paper tied to the mediation statement issue
contracts, receipts, invoices, photos and estimates
messages showing promises, deadlines, refusals or admissions
proof of payment, delivery, service and attempted resolution
court forms, filing receipts, service records and hearing notices
a one-page exhibit list with dates and short labels
Steps Before You Send
Check the correct court, claim limit, defendant name and deadline before drafting.
Name the mediation statement issue in one sentence so the reader can see the exact route you are using.
Send a final demand or response that explains the claim in numbered facts.
Organize exhibits by issue, not by file type.
Prepare for mediation and hearing questions separately.
Keep settlement terms written and specific before dismissing any claim.
Common Mistakes
suing the wrong legal name
bringing every document instead of a clear exhibit packet
forgetting proof of service
settling without a payment date and default consequence
How Caira Can Help
Before threatening court, ask Caira by Unwildered to turn the documents into a demand, exhibit list and settlement checklist.
Caira is powered by AI and can read your PDFs, photos, docs, receipts and screenshots, then give answers, evidence summaries and draft letters in seconds.
Where To Check The Rules
local small-claims court instructions
state court self-help forms
service of process and evidence rules for the filing forum
FAQ
Should I stop paying immediately?
Not always. Stopping payment can create late fees, service cutoffs, credit reporting, default notices or collection activity. First identify the contract, charge, deadline and safest route.
Should I name a company in the letter?
Yes, if it is the company you dealt with. Keep the wording factual: account number, date, promise, charge and requested fix. Do not accuse fraud unless you have a documented evidence.
Can this become a small-claims issue?
Sometimes. If the amount is documentable and the company will not respond, a demand letter and evidence index may help you decide whether small claims is worth considering.
This article is general information, not legal, financial, tax or medical advice. US law varies by federal rule, state rule, contract wording, forum, timing and facts.
