COURT OF APPEAL, FIRST APPELLATE DISTRICT CASE SCREENING FORM This form should be submitted to the clerk of the Court of Appeal for transmittal to the mediation program administrator. The form will not be entered in the court file. Attach pertinent documents, e.g., any judgment, findings of fact, statement of decision, or order appealed from. Attach additional pages if necessary. Enter e-mail address. This form must be typed. You may find a fillable PDF form at this link: http://www.courts.ca.gov/documents/csscreen.pdf Case Name: Your Name: Counsel for: Subject Matter (Check all that apply): Attorney's Family Law Personal Fees Injury Construction Intellectual Property Professional Negligence Case No: State Bar No.: Business/Contract Insurance Probate Employment Medical Malpractice Real Estate Other (specify): Number of Parties: Appellant: Firm: Address: Telephone: Date Notice of Appeal Filed: Counsel: FAX: E-mail: Respondent Firm: Address: Telephone: Counsel: FAX: E-mail: Cross-Appellant: Counsel: American LegalNet, Inc. www.FormsWorkFlow.com Firm: Address: Telephone: FAX: E-mail: Other Parties: See Attachment. Trial Court: Trial Judge: The trial court judgment resulted from: Jury Trial Dismissal Court Trial Nonsuit Summary Judgment Arbitration Award Demurrer Administrative Mandamus Case No.: Order (specify): Other (specify): What was the judgment?: What was the last settlement demand? $ Offer $ Identify all ADR processes in this case in which you have participated (e.g., mediation, arbitration, or settlement conferences). State the name of all judges, mediators, or other neutral parties involved: Briefly state the facts of this case: 2 American LegalNet, Inc. www.FormsWorkFlow.com List the appellate issues that you anticipate: This is a case of first impression. (Specify): This case principally involves the validity or interpretation of a statute, ordinance, or regulation. (Specify): Related case or cases: Name: Court: No. What is the outcome that you seek in this case? Damages (specify): $ Equitable Relief: (specify): Other (specify): Describe any ongoing personal, professional, or business relationship between any of the parties to this appeal: Identify all persons, other than the parties, whose agreement is necessary for the settlement of this appeal and any related litigation or dispute (e.g., an insurance adjuster, spouse, or lien holder): What else should be considered in determining whether this case should be submitted to mediation? 3 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT 4/11/12 4 American LegalNet, Inc. www.FormsWorkFlow.com