Or Modify A State Or Tribal Government Veterans Cemetery
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1
2ADR-100
MEDIATOR (Name and Address):
FOR COURT USE ONLY
To keep other people from seeing
what you entered on your form,
please press the Clear This Form
button at the end of the form when
finished.
TELEPHONE NO.:
FAX NO.:
E-MAIL ADDRESS:
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
The mediator must complete, serve, and file this form
•
within 10 days after conclusion of the mediation, or by an another date set by the court, in all cases
assigned to mediation under the Civil Action Mediation Program. (Code Civ. Proc., § 1775 et seq.)
•
as required by the court in other mediation programs.
In completing this form, the mediator must not
•
provide any information beyond what is specifically requested, or
•
disclose any settlement terms, confidential communications, mediation conduct, or mediator conclusions or
impressions. (Evid. Code, § 1115 et seq.)
1.
I was appointed, assigned, or retained as the mediator in this case on (date):
2.
The mediation (check one)
a.
was not scheduled.
b.
was scheduled but not held.
c.
was held as follows:
(1)
Session dates (specify all):
(2)
Number of sessions:
(3)
Total length of sessions (hours):
3.
The mediation ended on (date):
a.
in a full agreement.
b.
in a partial agreement.
c.
in nonagreement.
The mediation has not yet ended. I submit this form to comply with the court’s requirement to do so by a specified date.
4.
(Complete the items below. In Civil Action Mediation Programs and where otherwise required by the court, file a supplemental
Statement of Agreement or Nonagreement within 10 days after the mediation ends or by such other date as the court may set.)
a. The mediator anticipates that the mediation will be completed by (date):
NOTICE TO PARTIES: This form does not extend any mediation completion deadline that the court has set.
You must request any necessary extension from the court.
b. The next mediation session is scheduled for (date):
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF MEDIATOR)
Page 1 of 2
Form Adopted for Mandatory Use
STATEMENT OF AGREEMENT OR NONAGREEMENT
Code of Civil Procedure, § 1775.9
Judicial Council of California
Cal. Rules of Court, rule 3.895
ADR-100 [Rev. July 1, 2012]
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