MEDIATOR (Name and Address):
COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : :
TELEPHONE NO.: FAX NO. (Optional):
Index No. Calendar No.
FOR COURT USE ONLY
E-MAIL ADDRESS (Optional):
: : : :
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:
Defendant(s) : ......................................................
STATEMENT OF AGREEMENT OR NONAGREEMENT
THE PEOPLE OF THE STATE OF NEW YORK NOTE: This form must be used by mediators in the Civil Action Mediation Program (Code Civ. Proc., § 1775 et seq.) and in the Early Mediation Pilot Program (Code Civ. Proc., § 1730 et seq.).
1. This case was filed on (date if known): 2. I was selected as the mediator in this matter on (date): 3. Mediation (check one): a. did not take place. WE COMMAND YOU, that all business and excuses being laid aside, (1) A party who was ordered to appear at the mediation did not appear.
you and each of you attend before
, the Honorable at the Court (2) Other reason (please specify without disclosing any confidential information): located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the
took place on (date or dates): and lasted a total of hours.
Your failure to comply with this form to comply with the court's contempt of do so by a specified date. The mediation has not ended. I submitthis subpoena is punishable as a requirement tocourt and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 5. The mediation ended (check comply. result of your failure to one):
4. a. b.
Witness, Honorable in full agreement as to the following parties: Court in County, day of , 20
(1) on (date): in full agreement as to limited issues on (date): (2) in nonagreement.
in full agreement by all parties on (date): in partial agreement
, one of the Justices of the
(Attorney must sign above and type name below)
(TYPE OR PRINT NAME) (SIGNATURE OF MEDIATOR)
NOTE: Within 10 days of the conclusion of the mediation or, when applicable, by the deadline set by the court, the mediator must serve a copy of this statement on all parties and file the original, with proof of service, with the court clerk. The proof of service on the back of this form may be used.
Office and P.O. Address
Form Adopted for Mandatory Use Judicial Council of California ADR-100 [Rev. January 1, 2003]
Telephone No.: Facsimile No.: E-Mail Address: STATEMENT OF AGREEMENT OR Mobile Tel. No.: NONAGREEMENT
Page 1 of 2 Code of Civil Procedure, §§ 1739, 1775.9
American LegalNet, Inc. www.USCourtForms.com
PROOF OF SERVICE Mail Personal Service
1. At the time of service I was at least 18 years of age and not a party to this legal action. 2. My residence or business address is (specify):
3. I mailed or personally delivered a copy of the Statement of Agreement or Nonagreement as follows (complete either a or b): Mail. I am a resident of or employed in the county where the mailing occurred. a. (1) I enclosed a copy in an envelope and (a) deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid. placed the envelope for collection and mailing on the date and at the place shown in items below, following (b) our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service, in a sealed envelope with postage fully prepaid. (2) The envelope was addressed and mailed as follows: (a) Name of person served: (b) Address on envelope:
(c) Date of mailing: (d) Place of mailing (city and state): b. Personal delivery. I personally delivered a copy as follows: (1) Name of person served: (2) Address where delivered:
(3) Date delivered: (4) Time delivered: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF DECLARANT)
ADR-100 [Rev. January 1, 2003]
PROOF OF SERVICE FOR STATEMENT OF AGREEMENT OR NONAGREEMENT
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