Fill and Sign the Alternative Dispute Resolution Statement to Form

ADR-111REFEREE (Name, State Bar number, if applicable, and address): FOR COURT USE ONLY TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER:REPORT OF REFEREE 1. Appointment. The undersigned referee was appointed as follows:a. Date. By order dated: b. Statutory authority. Referee was appointed under (check one):(1) Code of Civil Procedure section 638.(2) Code of Civil Procedure section 639.2. Submission. The hearing, if any, was concluded and the matter was submitted on (date): 3. Referee's time and fees. (All items must be completed if referee was appointed under section 639.)a. Total hours spent by referee: b. Total fees charged by referee: c. Referee recommends the following allocation of payment of referee's fees (state the recommended allocation below or inAttachment 3c): 4. Recommendation on the merits. (State the recommendation on the merits of any disputed issues below or in Attachment 4.) 5. Pages and attachments. Number of pages attached: Date: (NAME OF REFEREE) (SIGNATURE OF REFEREE)Page 1 of 2Form Approved for Optional UseJudicial Council of California Code of Civil Procedure, § 643ADR-111 [New January 1, 2006] REPORT OF REFEREE (Alternative Dispute Resolution) electronic form  2005 WWW.LawCA.com Law Publishers ADR-111PETITIONER/PLAINTIFF: CASE NUMBER:RESPONDENT/DEFENDANT: DECLARATION OF SERVICE OF REPORT OF REFEREE1. I am at least 18 years of age, not a party to this action, and I am a resident of or employed in the county where the mailing took place.2. My residence or business address is: 3. I served a copy of the Report of Referee (Alternative Dispute Resolution) (form ADR-111) by enclosing it in a sealed envelope with postage fully prepaid, as follows:a. I deposited the sealed envelope with the United States Postal Service with the postage fully prepaid.b. I placed the envelope for collection and processing for mailing following this business's ordinary practice with which I am readily familiar. 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.c. Date of deposit: d. Place of deposit (city and state): e. Addressed as follows (name and address of each party): 4. 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-111 [New January 1, 2006] REPORT OF REFEREE Page 2 of 2(Alternative Dispute Resolution)