California > Local County > Los Angeles > Alternative Dispute Resolution
ADR Case Referral Intake Form ADR 039 - California
| ADR Case Referral Intake Form Form. This is a California form and can be used in Alternative Dispute Resolution Los Angeles Local County . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Superior Court of California, County of Los Angeles JOHN A. CLARKE, EXECUTIVE OFFICER/CLERK ALTERNATIVE DISPUTE RESOLUTION (ADR) ADR CASE REFERRAL INTAKE (Please type or print clearly) CASE INFORMATION Case Number: Case Name: Litigation Type: ADR Process: Civil MEDIATION Family Law Probate Other (specify): _________________________________________________ NEUTRAL EVALUATION ADR Completion Date: SETTLEMENT CONFERENCE Courthouse: Dept.: ARBITRATION Case Type: See Page 2 Amount in Dispute: Plaintiff/Petitioner or attorney: $0-$25,000 $50,000-$100,000 $250,000-$500,000 $750,000-$1,000,000 $25,000-$50,000 $100,000-$250,000 $500,000-$750,000 Over $1,000,000 ---------------------------------------------------------------------------------------------------$0-$25,000 $50,000-$100,000 $250,000-$500,000 $750,000-$1,000,000 Defendant/Respondent or attorney: $25,000-$50,000 $100,000-$250,000 $500,000-$750,000 Over $1,000,000 NEUTRAL SELECTION Party Select Panel: The parties select the following Neutrals in order of preference from the Court ADR Party Pay Panel and acknowledge they are undertaking a financial commitment in selecting a Party Pay Panel Neutral. 1) NAME: ___________________________________________________________ 2) NAME: ___________________________________________________________ _____________________________________________________________ (signature of plaintiff/petitioner or attorney) ADDITIONAL SIGNATURES LISTED ON ATTACHED PAGE NEUTRAL NO.: ____________________________ NEUTRAL NO.: ____________________________ _____________________________________________________________ (signature of defendant/respondent or attorney) Random Select Panel: The parties understand that a Neutral from the Court ADR Pro Bono Panel will be assigned on a random basis (civil mediation and arbitration only). NAME OF ASSIGNED NEUTRAL: ___________________________________________________________ NEUTRAL NO.: ____________________________ PARTIES ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ___________________________________________________________________ (party name) (party type) ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ) STATE: FAX: ( ) ZIP: ) STATE: FAX: ( ) ZIP: ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ____________________________________________________________________ (party name) (party type) ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ) STATE: FAX: ( ) ZIP: ) STATE: FAX: ( ) ZIP: ___________________________________________________________________ ____________________________________________________________________ (party name) (party type) (party name) (party type) ADDITIONAL PARTIES LISTED ON PAGE THREE FOR OFFICE USE ONLY Received by: ________________________________ ___________________________ Name Date LAADR 039 (Rev. 04/09) LASC Approval 10-04 Case Mgr Assigned: ________________________________ _____________________ Name Date Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com ADR CASE REFERRAL INTAKE (continued) Case Name: Case Number: CASE SELECTION CRITERIA CASE TYPE Antitrust/Trade Regulation Auto Tort - Personal Injury/Property Damage/Wrongful Death (PI/PD/WD) Auto Tort - Uninsured Motorist - PI/PD/WD Civil Harassment Construction Defect Contract - Breach of Rental/Lease Contract (not insurance, UD, or wrongful eviction) Contract - Collections Contract - Contract/Warranty Breach - Seller Plaintiff (not insurance, fraud, or negligence) Contract - Contractual Fraud Contract - Insurance Coverage/Subrogation Contract - Negligent Breach of Contract/Warranty (not insurance or fraud) Contract - Other Breach of Contract/Warranty (not insurance, fraud, or negligence) Contract - Tortious Interference Declaratory Relief Only Elder/Dependent Adult Abuse Employment - Labor Commissioner Appeals Employment - Other (not wrongful termination or labor commissioner appeal) Employment - Wrongful Termination Family Injunctive Relief Only (not domestic/harassment) Non-PI/PD/WD Tort - Business/Commercial Tort (not fraud or breach of contract) Non-PI/PD/WD Tort - Civil Rights (e.g., discrimination, false arrest) Non-PI/PD/WD Tort - Defamation (e.g., slander, libel) Non-PI/PD/WD Tort - Fraud (no contract) Non-PI/PD/WD Tort - Intellectual Property Non-PI/PD/WD Tort - Legal Malpractice Other PI/PD/WD Tort - Asbestos Other PI/PD/WD Tort - Intentional (e.g., assault, vandalism, etc.) Other PI/PD/WD Tort - Intentional Infliction of Emotional Distress Other PI/PD/WD Tort - Medical Malpractice Other PI/PD/WD Tort - Premises Liability Other PI/PD/WD Tort - Product Liability (not asbestos, toxic/environmental) Partnership & Corporate Governance Probate Real Property - Eminent Domain/Condemnation Real Property - Mortgage Foreclosure Real Property - Quiet Title Real Property - Wrongful Eviction Real Property - Other Securities Toxic Tort/Environmental Workplace Harassment Writ of Mandate Do you need a neutral who accepts cases on short notice? Jurisdiction Type: Unlimited Limited Yes No Language ability needed other than English: ADA Accommodations Accessible parking Accessible elevators Accessible public phones Accessible tables/counters Location: Zip Code: LAADR 039 (Rev. 04/09) LASC Approval 10-04 Accessible entrance Accessible restrooms Accessible listening devices Other (specify): City: Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com ADR CASE REFERRAL INTAKE (continued) (This Form Must Be Completed In Detail) Case Name: Case Number: ADDITIONAL PARTIES ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ___________________________________________________________________ (party name) (party type) ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ___________________________________________________________________ (party name) (party type) ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ___________________________________________________________________ (party name) (party type) ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ___________________________________________________________________ (party name) (party type) ) STATE: FAX: ( ) ZIP: ) STATE: FAX: ( ) ZIP: ) STATE: FAX: ( ) ZIP: ) STATE: FAX: ( ) ZIP: ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: ___________________________________________________________________ (party name) (party type) ATTORNEY NAME: FIRM: ADDRESS: CITY: PHONE: ( E-MAIL: ATTORNEY FOR: __
|
|||||||
