Free Qualification Statement (CV\E-119) - California

SUPERIOR COURT OF CALIFORNIA
County of Sacramento 720 Ninth Street, Room 102 Sacramento, CA 95814-1380 (916) 874-5522--Website www.saccourt.ca.gov
Arbitrator (Name, State Bar # and Address):

For Court Use Only

Telephone No.: E-Mail Address: Plaintiff: Defendant:

Fax No.:

Case Number:

Assigned Dept:

Qualification Statement
Qualification pursuant to CRC, rule 3.816

It shall be the duty of the arbitrator to determine whether any cause exists for his/her disqualification in the case he/she is to hear upon any of the grounds set forth in Section 170 et seq. of Code of Civil Procedure governing the disqualification of judges. If any member of the arbitrator's law firm would be disqualified under subdivision 4 of Section 170 et seq., the arbitrator is disqualified. Unless the ground for disqualification is disclosed to the parties in writing and is expressly waived by all parties in writing, the arbitrator shall promptly notify the Arbitration Unit of any known ground for disqualification, and another arbitrator shall be selected as provided in rule 3.815 of the California Rules of Court. I certify that I have read the foregoing rule and I know of no cause for my disqualification. Executed on __________________, at ____________________, California Arbitrator
Arbitrators may not solicit private mediation business of the parties or attorneys in the matter being arbitrated or charge separately for services beyond what the Court pays.

Qualification Statement CV\E­ARB­119 (Rev 02.13.09) Local Form Adopted for Mandatory Use Page 1 of 1