SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE ARBITRATOR FEE STATEMENT This form is for members of the Civil Arbitration Panel who provided a Court-Ordered Arbitration pursuant to Local Rule, Title 3, Division 2. Please submit this form within ten (10) days of the filing of the Arbitration Award to the Coordinator of ADR Services: 4050 Main Street, Riverside, CA 92501; CourtADRDirector@riverside.courts.ca.gov RI-ADR08 SECTION A. ARBITRATOR'S INFORMATION Arbitrator's Name: Email Address: Phone Number: THIS INFORMATION MUST MATCH THE INFORMATION ON YOUR VENDOR PAYEE FORM Make Check Payable to: Remit to Address: (ADDRESS) (CITY) (STATE) (ZIP CODE) SECTION B. ARBITRATION INFORMATION Case Name: Date(s) of Arbitration: Case No.: Length of Session(s): I certify that I was the arbitrator in the above-entitled case that was arbitrated pursuant to Local Rule Title 3, Division 2. I certify that at the time the arbitration was held I was an active member of the Court's Civil Arbitration Panel. As confirmation of my service: 1. Date Case Ordered to Arbitration: 2. Date Assigned as Arbitrator on this Matter: 3. Date Arbitration Award Filed: I request payment of $150.00 for my services. SECTION C. ARBITRATOR'S DECLARATION I declare under penalty of perjury the foregoing to be an accurate statement of services rendered in this case. (SIGNATURE OF CLAIMANT) (DATE) Fund: Cost Center: For Court Use Only 110001 335340 1220 939101 Date: PECT/Functional Area: GL: Approvers Initials: Approvers Printed Name: COMMENTS: Approved Fee: $150.00 Page 1 of 1 Adopted for Mandatory Use Riverside Superior Court RI-ADR08 [Rev. 09/09/2014] ARBITRATOR FEE STATEMENT riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com