PARTY: (Name and Address): TELEPHONE NO: E-MAIL ADDRESS (Optional): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF CONTRA COSTA MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CASE NAME: P.O. BOX 911 MARTINEZ, CA 94553 MARTINEZ DO NOT SEND THIS FORM TO THE COURT CASE NUMBER: JUDICIAL ARBITRATION STATEMENT PARTIES MUST PREPARE AND GIVE INFORMATION ABOUT THEIR CASE TO THE ARBITRATOR AND THE OTHER PARTIES AT LEAST FIVE COURT DAYS BEFORE THE JUDICIAL ARBITRATION HEARING. YOU MAY USE THIS FORM OR WRITE THE INFORMATION ON YOUR OWN PAPER. ARBITRATION STATEMENTS MUST BE 5 PAGES OR LESS. 1. The name and title (or relationship to the case) of all people who will attend judicial arbitration are: _______________________________________________ _______________________________________________ (NAME) _______________________________________________ (NAME) _______________________________________________ (NAME) _______________________________________________ (NAME) (TITLE) _______________________________________________ (TITLE) _______________________________________________ (TITLE) _______________________________________________ (TITLE) More information attached to this form. 2. The important issues in this case are as follows: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ More information attached to this form. 3. I believe that the liability and damages in this case are as follows: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ More information attached to this form. American LegalNet, Inc. www.FormsWorkFlow.com ADR-404/Rev. 11/24/10 4. Summary of the history of this case: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ More information attached to this form. 5. I have attached the following documents to help the arbitrator better understand the issues in dispute: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ More information attached to this form. 6. Other comments: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ More information attached to this form. Date: _______________________________________________ (TYPE OR PRINT NAME OF PARTY SUBMITTING THIS ARBITRATION STATEMENT) _______________________________________________ (SIGNATURE OF PARTY SUBMITTING THIS ARBITRATION STATEMENT) ADR-404/Rev. 11/24/10 American LegalNet, Inc. www.FormsWorkFlow.com