Fill and Sign the Ca Agreement Form

                                                                                                      and lasted a total of                                           ADR-100 MEDIATOR (Name 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: CASE NAME: CASE NUMBER: STATEMENT OF AGREEMENT OR NONAGREEMENT First Supplemental 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. (1) (2) A party who was ordered to appear at the mediation did not appear. Other reason (please specify without disclosing any confidential information): b. took place on (date or dates): hours. 4. The mediation has not ended. I submit this form to comply with the court's requirement to do so by a specified date. 5. The mediation ended (check one): a. b. in full agreement by all parties on (date): in partial agreement (1) in full agreement as to the following parties: on (date):(2) in full agreement as to limited issues on (date): c. in nonagreement. Date: (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. Page I of 2 Form Adopted for Mandatory Use Judicial Council of California ADR-100 [Rev. January 1, 2003] STATEMENT OF AGREEMENT OR NONAGREEMENT Code of Civil Procedure, §§ 1739, 1775.9elec troni c form  2002 WWW.LawCA.com L a w P u b l i s h e r s                                                                                                CASE NAME: CASE NUMBER: 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 orb): a. Mail. I am a resident of or employed in the county where the mailing occurred. (1) I enclosed a copy in an envelope and (a) (b) 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 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-1 00 [Rev. January 1, 2003] PROOF OF SERVICE FOR STATEMENT OF AGREEMENT OR NONAGREEMENT Page 2 of 2elec troni c form  2002 WWW.LawCA.com L a w P u b l i s h e r s