Form 64 — Notice of Non-Resolution by Mediation

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(Rule 105(20))

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(Title Form 1)

Take notice that in the matter of the mediation of Space to insert name of bankrupt , bankrupt, which was held on the Space to insert day day of Space to insert month Space to insert year, the issues submitted to mediation were not resolved because the parties have failed to reach an agreement.

Dated at Space to insert city , this Space to insert day day of Space to insert month Space to insert year .

Space to insert mediator's signature
Mediator

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