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Ive of the account holder. Signature of Account Owner or Authorized Representative: Date: __________ CERTIFICATION FOR MEDIATION REQUEST I understand that any mediation proceedings are confidential and that if I choose to participate in Verizon’s internal voluntary mediation program, I cannot use any statements made during it to settle my dispute in any subsequent legal proceeding, including arbitration or a small claims proceeding, between Verizon and myself, or my client. I will not disclose.

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