SUPERIOR COURT OF CALIFORNIA, COUNTY OF AMADOR 500 ARGONAUT LANE, JACKSON, CA 95642 Name, Address and Telephone No. of Mediator/Evaluator CLERK'S USE ONLY Telephone No: Case Title: Case No. Invoice Date: FAMILY LAW AND CIVIL MEDIATION CLAIM FORM AND ORDER CLAIM AND REQUEST FOR APPROVAL OF: FAMILY LAW MEDIATION FEES CIVIL MEDIATON FEES EVALUATOR'S FEES To the Judge of the Superior Court: Pursuant to No. 5 of the General Mediation Procedures adopted by the Amador County Superior Court, there is herewith presented a claim for fees in the above-entitled cause: FAMILY LAW MEDIATION GL #939101 Agreement Partial Agreement No Agreement Petitioner did not show for Mediation Respondent did not show for Mediation TIME/HOURS _____________ Refer for Evaluation Other: __________ ____________________ Recommended for Minor's Counsel (FC 3184) $210.00 Set fee for mediation $105.00 Quarterly Meeting $50.00 One or both parties did not show Mediator: ____________________________________ Date:____________________________ (For Statistical Purposes Only) Did the issues in mediation involve Domestic Violence Not Applicable Substance Abuse Child Abuse CIVIL MEDIATION ($150.00) FAMILY LAW EVALUATION ($600.00 per client) Mediation Date: ____________________ TOTAL CLAIM: $________________ I declare under penalty of perjury that the itemized statement and claim for services attached hereto is true and correct and accurately reflects the time spent by me in this action. Date:____________________ Date:____________________ Mediator/Evaluator: __________________________________________ ____________________________________________________________ Barbara Cockerham, Court Executive Officer ______________________________________________________________________________________________________ ORDER Amount Approved: $_________________ Date: ____________________ ____________________________________________________________ Judge of the Superior Court MEDIATION AND EVALUATOR'S CLAIM FORM AND ORDER-(Rev. 10/05/2012)-FIN-022 American LegalNet, Inc. www.FormsWorkFlow.com ITEMIZED STATEMENT CASE NO.: SERVICE DATE TYPE OF SERVICE # OF HOURS RATE COST TOTAL # OF HOURS ________ X $_________/HOUR = $ ____________________________ Date ______________________________________ Signature MEDIATION AND EVALUATOR'S CLAIM FORM AND ORDER-(Rev. 10/05/2012)-FIN-022 American LegalNet, Inc. www.FormsWorkFlow.com