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Application For Financial Aid For ADR Services ADR-9 - California
| Application For Financial Aid For ADR Services Form. This is a California form and can be used in ADR San Mateo Local County . |
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Multi-Option ADR Project Superior Court of San Mateo County 400 County Center, Redwood City, CA 94063-1655 Tel: (650) 599-1073 / Fax (650) 599-1754 Civil & Probate ADR Program Financial Aid Request Instructions In some instances, a party in a lawsuit may have difficulty paying a mediator/ADR neutral's hourly fees. If this is the case, a party can apply for a full or partial waiver of these fees by completing the attached financial aid application and submitting it to the court's ADR offices within five business days of their referral to ADR and/or their case management hearing. If financial assistance is granted to one party in a case, it does NOT effect the portion of the ADR neutral's fees paid by the other parties in the case. Neutrals waive fees for up to 6 hours of work. To apply for financial assistance for ADR services, you need to: 1) Complete the attached Financial Aid Application. This information is confidential and will not be placed in the court case files. If you do not qualify for a complete waiver of fees, you still may qualify for a partial waiver, and will be asked to contribute fees on a reduced basis. 2) If an application is granted, all the parties in a case must then select the names of 4-5 mutually agreed upon neutrals from the Financial Aid Panelist List. Parties must submit those names within the time specified by ADR staff. Note: If the list of mutually agreed upon neutrals is not received within the time specified, the financial assistance may be withdrawn. The list of potential neutrals submitted to the ADR offices can include the name of only one retired judge. Resumes of panel neutrals can be found on the court's website at www.sanmateocourt.org/adr. 3) Assignment of a neutral and scheduling of ADR session. ADR staff will notify counsel/parties which MAP panelist has been assigned to handle the case. After the neutral is assigned, parties schedule the ADR session directly with the neutral's office. 4) Parties execute and file a Stipulation and Order to ADR with the Clerk of the Court, identifying the name of the neutral and the date of the ADR session. If parties fail to file the required Stipulation & Order to ADR within the specified time, the assigned neutral may be released from his/her obligation to handle the case. These services are offered as a courtesy and, if not properly utilized, can be withdrawn at the discretion of ADR staff. The granting or denying of financial assistance by ADR staff has no bearing on future court proceedings. This application is used solely for purposes of determining a party's ability to pay for mediation/ADR services. Please contact ADR Program staff directly if you have any further questions at (650) 599-1073 or (650) 599-1070. American LegalNet, Inc. www.FormsWorkFlow.com Multi-Option ADR Project Superior Court of San Mateo County 400 County Center, Redwood City, CA 94063-1655 Tel: (650) 599-1073 / Fax (650) 599-1754 Application for Financial Aid for ADR Services Do not fill out this form if you filed an Application for Waiver of Court Fees and Cost! If granted, attach a copy of the Judge's Order to this application. Name: ___________________________________ Address: __________________________________ Number Street __________________________________________ City State Zip Case Name: _______________________ _________________________________ _________________________________ Phone No.: (____) __________________________ Your Place of Birth: Date of Birth: ____ / ___ / ______ Gender: _______ Answer the Following questions: 1. Are you self-employed or do you have a job now? Yes No N/A Case No: _________________________ _________________________________ City State Name of your employer: Do you expect to be working soon? Do you get any money from any other source (welfare, pension, unemployment, disability, alimony, spousal support, etc.)? 4. Are you married? 5. Does your spouse have a job? 6. Does your spouse get any money from any other source? 7. Do you own, or are you buying your home? 8. Do you have a checking account? 9. Do you have a savings account? 10. Does your spouse have a checking account? 11. Does your spouse have a savings account? 12. Do you or your spouse own: 2. 3. · · · · a car? stock or bonds? jewelry? trailer or boat American LegalNet, Inc. www.FormsWorkFlow.com 13. If you are unemployed, how have you supported yourself while unemployed? _____________________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Your Assets & Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ Your Monthly Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Monthly Expenses: $ Your take-home pay per month Your spouse's take-home pay per month Other income per month Money in your savings account Money in your spouse's savings account Money in your checking account Money in your spouse's checking account Equity in real estate Money owed to you Money at home (cash) Amount of tax refund you will receive Cash value of your insurance Cash value of your spouse's insurance Cash value of autos, trucks, trailers and/or boats Rent payment per month Mortgage payment per month Food Utilities (gas, electric, phone, garbage) Insurance (Medical, Dental, Life, Auto, etc.) Monthly Credit payments Child care expenses Clothing Medical/Dental (not covered by insurance) Spousal support or alimony you pay Transportation (car payments, bus, train, etc.) IRS/Franchise Tax Board payments Other expenses: (specify) Total Assets & Income: $ I declare that all the information provided above is true and accurate. Date: ____ / ___ / ______ _______________________________________ Signature of Applicant Instructions: · Submit this application to the MAP offices within 5 business days of your case management conference hearing. You can fax it to (650) 599-1754. · If you are represented by an attorney, attach a copy of the attorney-client fee/ retainer agreement · Do not serve a copy of this application on opposing counsel. All information in this application will be kept confidential and reviewed by court ADR staff. For office use only: Approved Denied Pro Bono Modest means Date: ____ / ___ / ______ Reviewer: ____________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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