AMERICAN ARBITRATION ASSOCIATION SUPPLEMENTARY PROCEDURES FOR CONSUMER-RELATED DISPUTES (FOR USE ONLY IN CALIFORNIA) Pursuant to Section 1284.3 of the California Code of Civil Procedure, consumers with a gross monthly income of less than 300% of the federal poverty guidelines are entitled to a waiver of arbitration fees and costs, exclusive of arbitrator fees. This law applies to all consumer agreements subject to the California Arbitration Act, and to all consumer arbitrations conducted in California. If you believe that you meet these requirements, you must submit to the AAA a declaration under oath regarding your monthly income and the number of persons in your household. Please contact the AAA’s Western Case Management Center at 1-877-528-0879, if you have any questions regarding the waiver of administrative fees. How to file a claim; businesses should: How to file a claim; consumers should: • Fill out this form and retain one copy for your records. • Mail two copies of this form and your check or money order made payable to the AAA, to the AAA Case Management Center nearest to you. Please consult Section C-8 of the Supplementary Procedures for ConsumerRelated Disputes for the appropriate fee. • Send a copy of this form to the consumer by registered mail return receipt requested. • Fill out this form and retain one copy for your records. • Mail two copies of this form and your check or money order made payable to the AAA, to the AAA Case Management Center nearest to you. Please consult Section C-8 of the Supplementary Procedures for ConsumerRelated Disputes for the appropriate fee. • Send a copy of this form to the business. 1 How is this claim being filed? Check only one. [ ] By request of the consumer (A copy of the arbitration agreement must be attached. A copy of this form must also be sent to the business) [ ] By request of the business (A copy of the arbitration agreement must be attached. A copy of this form must also be sent to the consumer by registered mail return receipt requested) -or[ ] By mutual agreement (“submission”) of the parties (both parties must sign this form) 2 Briefly explain the dispute. 3 Do you believe there is any money owed to you? If yes, how much? 4 Is there any other outcome you want? If yes, what is it? 5 Preferred hearing locale (if an in-person hearing is held) ______________________________________________ 6 Fill in the following information [ ] Yes [ ] No Consumer Business Name of Consumer ______________________________ Address _______________________________________ Name of Business ___________________________ Address ___________________________________ City/State/Zip___________________________________ City/State/Zip_______________________________ Telephone _____________________________________ Telephone _________________________________ Fax ___________________________________________ Fax _______________________________________ Signature of Consumer ___________________________ Signature of Business ________________________ Representative __________________________________ Representative _____________________________ Firm __________________________________________ Firm _____________________________________ City/State/Zip___________________________________ City/State/Zip_______________________________ Telephone _____________________________________ Telephone _________________________________ Fax ___________________________________________ Fax _______________________________________ AAA Web site: www.adr.org American LegalNet, Inc. www.USCourtForms.com