California > Local County > Riverside > Arbitration
Mediators Fee Statement RI-ADR07 - California
| Mediators Fee Statement Form. This is a California form and can be used in Arbitration Riverside Local County . |
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MEDIATOR'S FEE STATEMENT This form is for members of the Civil Mediation Panel who provided a Court-Ordered Mediation pursuant to Local Rule, Title 3, Division 2 . Please submit this form within ten (10) days of the mediation to the ADR Director: Riverside County Superior Court, Historic Courthouse 4050 Main Street, Riverside, CA 92501 CourtADRDirector@riverside.courts.ca.gov For the latest information and current listing of telephone or fax numbers, please visit the court's website at: www.riverside.courts.ca.gov Mediator's Name: Case No.: Mediation Date(s): Plaintiff(s): Defendant(s): Length of Session(s): I certify that I was the mediator in the above-entitled case and that I timely filed and served a Statement of Agreement or Nonagreement as set forth in CRC 3.895. I provided the Post-Mediation Survey form to the parties and attorneys in this case. The Mediator's Record of Service is attached. I request payment of $150 for my services. DATE: Signature of Mediator Print Name ******************************* BELOW FOR COURT USE ONLY ******************************** I certify that this fee application has been submitted in compliance with court policy and the Court Executive Office is hereby ordered to issue payment in the amount of $150 payable to the above named person for services rendered in this case. Amount Authorized $ Date: Authorized by: Phone #: Accounting Codes Fund 110001; GL 939101 Cost Center 335340 PECT 1220 Page 1 of 1 Adopted for Mandatory Use Riverside Superior Court RI-ADR07 [Rev. 5/8/12] American LegalNet, Inc. www.FormsWorkFlow.com
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