STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT COURT ANNEXED ARBITRATION CERTIFICATE Providence/Bristol County Kent County Washington County Newport County PLAINTIFF(S) (Name each plaintiff individually) ________________________________________________ DEFENDANT(S) (Name each defendant individually) ________________________________________________ CIVIL ACTION NUMBER _______________________ Consolidated With _______________________ The undersigned certifies that the matter is subject to Court Annexed Arbitration according to Rule 1(a) of the Superior Court Rules Governing Arbitration of Civil Actions, and the monetary claim for relief in the amount of $_______________________ does not exceed $100,000. The last responsive pleading was filed on ________________________ (Date). ___________________________________________________________ Attorney for the Plaintiff Defendant or Self-represented litigant ___________________________________________________________ ___________________________________________________________ Address _______________________________________ Telephone A copy of this certificate was mailed to ____________________________________ (Name), Attorney for the Plaintiff Defendant or Self-represented litigant, at _______________________________________ ____________________________________ (Address) on ____________________________________ (Date). __________________________________ Certificate Signature REGISTERED USERS SHALL ELECTRONICALLY FILE THIS CERTIFICATE AND THE REQUIRED $100 FEE. ALL OTHERS MUST MAIL THIS CERTIFICATE AND THE REQUIRED $100 FEE TO THE ARBITRATION OFFICE AT THE LICHT JUDICIAL COMPLEX, 250 BENEFIT STREET, ROOM 531, PROVIDENCE, RI 02903. Processed by Arbitration Office Superior-31 (revised February 2015) American LegalNet, Inc. www.FormsWorkFlow.com