Case Name: ____________________________________________________ Date Notice of Appeal Filed: ______________________________________ COURT OF APPEAL, SIXTH APPELLATE DISTRICT MEDIATION STATEMENT FORM Case Number: You must return this form to the Clerk of the Court of Appeal within 15 days from the date it was mailed to you. (Ct. App., Sixth Dist., Local Rules, rule 1, subd. (e)(2).) ANY INFORMATION PROVIDED HEREIN WILL BE USED FOR T HE SOL E PURPOSE OF SCREENING YOUR APPEAL FOR INCL USION IN T HE M EDIATION PROGRAM. IT WILL REMAIN CONFIDENTIAL AND WILL NOT BE ENT ERED IN T HE COURT DOCKET OR FIL E. T HE COURT WILL NOT DEEM AN OMISSION FROM THIS STAT EM ENT TO BE A WAIV ER OR FORFEITURE OF ANY CLAIM ON APPEAL. (Check all that Apply) This Form is submitted on behalf of: Appellant Respondent Cross-Appellant Cross-Respondent Your Name: ____________________________________________________________________________ Represent: Self (party:) _________________________________________________ I/We DO NOT wish to participate in appellate mediation. (YOU MAY STOP HERE-you do not need to fill in the rest of this form) I/We wish to be considered for inclusion in the Court's Mediation Program. (Please complete the rest of this form as thoroughly as possible) **Due to budgetary constraints not all cases wishing to participate in mediation will be selected. Subject Matter Of the Appeal (Check all that apply): Attorney's Fees Construction Family Law Intellectual Property Personal Injury Prof.Negligence Business/Contract Employment Insurance Medical Malpractice Probate Real Estate Other (specify): ________________________________________________________________________________ Trial Court: _______________________________Trial Judge: _________________________________ The appealable judgment/order resulted from: Jury Trial Court Trial Summary Judgment Demurrer Dismissal Nonsuit Arbitration Award Mandamus Order (specify): ______________________Other (specify): ______________________________ We have previously participated in some form of ADR We have not participated in ADR Please Specify: ___________________________________________________________________________ Provide a concise statement of the case, including a brief factual and procedural history and list the issues you expect to raise on appeal (if any): (use additional shee ts if ne cessary) Please explain briefly why this appeal should be selected for the mediation program. 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): Please attach a separate sheet with your contact information, including name, firm name, address, phone, fax and email address. modified 1/2011 American LegalNet, Inc. www.FormsWorkFlow.com California Rules of Court, Sixth Appellate District Rule 1. MEDIATION 6/11/2010 (a) [Application of rule] This rule is adopted pursuant to rule 8.248, California Rules of Court, and shall apply to all civil appeals filed in the Sixth District Court of Appeal. (b) [Purpose of Mediation Program] To aid the expeditious and just resolution of civil appeals, the Court of Appeal for the Sixth District has established a mediation Program ("Program"). Procedures fo r mediation and operation of the Program shall be promulgated by and the Program shall be administered by the Administrative Presiding Justice or a designated Supervising Justice, and their designated staff. (c) [Scope of Mediation Program] At the court's discretion, any civil appeal may be placed in the Program if selected by the court or requested in writing by a party. The Court may, at its discretion, remove an appeal from the Program. (d) [Mediators] (1) The court shall maintain a list of attorneys who have developed expertise in specified areas of law, are gen erally respected in the legal community, and are willing to mediate cases at this court. These attorneys shall be designated as mediators and preside over mediations conducted within the scope of the Program. (2) A justice or assigned justice of this court may, at the court's discretion, be designated as a mediator and preside over a mediation. A justice or assigned justice who participates in a mediation that does not result in complete settlement shall not thereaft er participat e in any way in the consideration or disposition of the case on its merits. (3) A justice or assigned justice of the court will not be disqualified to participate in the consideration or disposition of a case on its merits because he or she has ruled on a request for a mediation, ordered that a mediation be held, signed orders granting relief from default for an act required under this rule, extended or shortened any time period speci fied in this rule, or otherwise signed an order concerning a procedural aspect o f the mediation process. (e) [General Mediation Program Procedure] (1) Upon receipt of notice o f the filing of a notice o f a civil appeal, the clerk of this court shall mail a copy of this rule and a Mediation Statement Form to counsel for all parties. (2) The Mediation Statement Form shall be returned to this court within 15 days from the date of mailing. Each party shall also serve a copy of their completed Mediation Statement Form on all other parties. (3) The Mediation Statement Form shall be transmitted by the Clerk to the Program and shall not be entered into the court file. (4) Within 15 days of receipt o f the Mediation Statement Forms, the court shall notify the parties when a case is selected for mediation and furnish the name, address and telephone number o f the mediator select ed fo r the mediation. The court shall provide three possible dates for mediation. (5) The parties shall meet and confer to agree on the date of mediation, and inform the court within 5 days of the date selected for mediation. The court will issue written notice of the date and time of the mediation. The mediator, with the approval of the Court, may, for good cause, postpone or continue a mediation session to a date certain. (6) The Court may replace a select ed mediator upon written request by a party supported by a showing of good cause or upon request of the mediator. (7) Immediately upon accept ance of a case into the Program, all further pro ceedings, including the filing of briefs, shall be suspended for 90 days. However, this rule shall not suspend preparation o f the appellate record unless a