I, ___________________________________, hereby accept appointment as evaluator in the above-captioned case.
I certify that I meet the qualifications of an evaluator, and shall timely and impartially discharge my obligations and duties as an evaluator. I have been informed of the identities of the parties to the case and the subject matter of the dispute and I have no conflict of interest or any bias that would prevent me from rendering a fair and impartial opinion in the dispute.
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Signature
SUBSCRIBED AND SWORN to before me this _______ day of ______, 20_.
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Signature
Id. Ct. Admin. R. 74