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         and la ste d a t o ta l o f            ADR-100MED IA TO R ( N am e a nd A ddre ss):F O R C O URT U SE O NLYT E LE PH O NE N O .:F A X N O . ( O ptio nal) :E -M AIL A D DR ESS ( O ptio nal) :SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS:MAILING ADDRESS:CITY AND ZIP CODE:BRANCH NAME:CASE N AM E:CASE N UM BER :S TA TE M EN T O F A G REEM EN T O R N O NAG REEM EN TFir s tS upple m en ta lN O TE : T his f o rm m ust b e u sed b y m ed ia to rs i n t h e C iv il A ctio n M ed ia tio n P ro gra m ( C ode C iv . P ro c., § 1 775 e t s eq .) a n d i n th e E arly M ed ia tio n P ilo t P ro gra m ( C ode C iv . P ro c., § 1 730 e t s eq .) .1 . T h is c ase w as f ile d o n ( d ate if k n ow n):2 . I w as s e le cte d a s t h e m ed ia to r i n t h is m atte r o n ( d ate ):3 . M ed ia tio n ( c h eck o ne):a .d id n ot t a ke p la ce .(1 )(2 )A p arty w ho w as o rd ere d t o a p pea r a t t h e m ed ia tio n d id n ot a p pear. Oth er r e as o n ( p le ase s p ecif y w it h out d is clo sin g a ny c o nfid entia l in fo rm atio n):b .to ok p la ce o n ( d ate o r d ate s):h ours .4 .T he m ed ia tio n h as n ot e n ded . I s u b m it t h is f o rm t o c o m ply w it h t h e c o urt's r e q uir e m en t t o d o s o b y a s p ecif ie d d ate .5 . T he m edia tio n e nded ( c h eck o ne ):a .b.in f u ll a gre em ent b y a ll p artie s o n ( d ate ): in p a rtia l a gre em ent(1 )in f u ll a gre em ent a s t o t h e f o llo w in g p artie s:o n ( d ate ):(2 )in f u ll a gre em ent a s t o lim it e d is su es o n ( d ate ):c .in n o nagre em ent.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F M ED IA TO R)N O TE : W it h in 1 0 d ays o f t h e c o nclu sio n o f t h e m ed ia tio n o r, w hen a p plic ab le , b y t h e d ead lin e s et b y t h e c o urt, t h e med ia to r m ust s e rv e a c o py o f t h is s ta te m en t o n a ll p artie s a n d f ile t h e o rig in al, w it h p ro of o f s erv ic e, w it h t h e c o urt cle rk . T he p ro of o f s erv ic e o n t h e b ack o f t h is f o rm m ay b e u sed .Page I of 2Form A dopte d fo r M andato ry U se Ju dic ia l C ouncil o f C alif o rn ia AD R -1 00 [R ev. J a nuary 1 , 2 003]S TA TE M EN T O F A G REEM EN T O R N O NAG REEM EN TCode of Civil Procedure, §§ 1739, 1775.9ele ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers          C ASE N AM E:CASE N UM BER :P R O OF O F S ER VIC EMailPers o nal S erv ic e1. A t t h e t im e o f s e rv ic e I w as a t le a st 1 8 y e ars o f a ge a nd n ot a p arty t o t h is l e g al a ctio n.2. M y r e sid ence o r b usin ess a ddre ss is ( s p ecif y ):3 . I m aile d o r p ers o nally d eliv e re d a c o py o f t h e S ta te m ent o f A gre em ent o r N onagre em ent a s f o llo w s ( c o m ple te e it h er a o rb ):a .M ail. I a m a r e sid ent o f o r e m plo ye d in t h e c o unty w here t h e m ailin g o ccu rre d. (1) I e nclo se d a c o py in a n e nve lo pe a nd(a )(b )d ep osit e d t h e s e ale d e nve lo pe w it h t h e U nit e d S ta te s P osta l S erv ic e , w it h t h e p osta ge f u lly p re paid . pla ced t h e e nve lo p e f o r c o lle ctio n a nd m ailin g o n t h e d ate a nd a t t h e p la ce s h ow n in it e m s b elo w , f o llo w in g our o rd in ary b usin e ss p ra ctic e s. I a m r e adily f a m ilia r w it h t h is b usin ess's p ra ctic e f o r c o lle ctin g a nd p ro ce ssin g corre sp ondence f o r m ailin g. O n t h e s a m e d ay t h at c o rre sp ondence is p la ce d f o r c o lle ctio n a nd m ailin g, it is de posit e d in t h e o rd in ary c o urs e o f b usin ess w it h t h e U nit e d S ta te s P osta l S erv ic e , in a s e ale d e nve lo pe w it hp osta ge f u lly p re pa id .(2 ) T he e nve lo pe w as a ddre sse d a nd m aile d a s f o llo w s:(a ) N am e o f p ers o n s e rv e d: (b) A ddre ss o n e nve lo pe:(c ) D ate o f m ailin g: (d) P la ce o f m ailin g ( c it y a nd s ta te ):b .P ers o nal d eliv ery . I p ers o nally d eliv e re d a c o py a s f o llo w s: (1 ) N am e o f p ers o n s e rv e d: (2) A ddre ss w here d eliv e re d:(3 ) D ate d eliv e re d: (4) T im e d eliv e re d:I d ecla re u nder p e nalt y o f p erju ry u nder t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F D EC LA R AN T)A D R-1 0 0 [R ev. J a nuary 1 , 2 003] P R O OF O F S E R VIC E F O R STA TE M EN T O F A G REEM EN T O R N O NAG REEM EN T Page 2 o f 2e le ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers