Court of Appeal Third Appellate District Appellate Case No: _____________________ ATTORNEY (Name, State Bar Number, Address) TRIAL COURT CASE NUMBER COUNTY: _________________________________ For Court Use Only Telephone No: Attorney For: APPELLANT: RESPONDENT: APPELLANT'S CIVIL APPEAL MEDIATION STATEMENT (USE ADDITIONAL SHEETS AS NECESSARY.) 1. Provide a concise statement of the case, including a brief procedural history and a recitation of facts material to disposition of the issues to be decided on appeal: 2. List the issues you expect to raise on appeal: Date: ____________________________________________ (Print or Type Name) _____________________________________________ (Signature of Attorney) _____________________________________________________________________________________________________________ ***A proof of service of this document on all counsel, prior to filing, must be attached. ________________________________________________________________________________________ _____________ NOTES: Recognizing the appellate record has not yet been prepared and that counsel and parties may not yet be able to identify all appellate contentions, the Court will not deem an omission from this Statement to be a waiver or forfeiture of any claim on appeal. This form is also online in fillable form at http://www.courts.ca.gov/3140.htm. Questions about the Appellate Mediation Program should be directed to the Appellate Mediation Coordinator at 916-643-7084. For general information about your appeal, please contact the clerk's office of the Third District Court of Appeal at 916-654-0209, or visit its web site at http://www.courts.ca.gov/3dca.htm; click on Court Programs, click on Mediation Program. For Use With the Third Appellate District Mediation Program 08/11/2008 American LegalNet, Inc. www.FormsWorkFlow.com