1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 was previously assigned to the Bankruptcy Mediation Program of this district and the 23 following individuals were appointed as Mediator and Alternate Mediator: 24 /// 25 /// 26 /// Form 704 Revised 11/09 UNITED STATES BANKRUPTCY COURT FOR THE CENTRAL DISTRICT OF CALIFORNIA In re ) ) ) ) ) ) Debtor(s). ) ) ) ) ) ) ) Plaintiff(s)/Movant(s), ) ) v. ) ) ) ) ) Defendant(s)/Respondent(s). ) ) This Bk. No. [Chapter ] Adv. No. NOTICE OF REQUEST AND REQUEST FOR APPOINTMENT OF SUCCESSOR MEDIATOR AND/OR SUCCESSOR ALTERNATE MEDIATOR TO MEDIATION PROGRAM (adversary proceeding/name of dispute in main case) 1 2 3 4 Mediator: Alternate Mediator: Name Firm Name Name Firm Name Address City, State, Zip Code Telephone The parties request appointment of the following individuals as Successor Alternate Mediator, due to (please check 5 6 7 City, State, Zip Code 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Firm Name 22 23 24 City, State, Zip Code 25 26 Telephone Form 704 Address Telephone 1. Successor Mediator and/or each that applies): (a) the unavailability of the Mediator and/or Alternate Mediator to serve in this Matter, or (b) Mediator. a conflict of interest of the Mediator and/or Alternate Successor Mediator: Successor Alternate Mediator: Name Name Firm Name Address City, State, Zip Code Telephone 2 Revised 11/09 Address 1 2 3 4 5 2. The parties are unable to agree upon a Successor Mediator and/or Successor Alternate Mediator, and hereby request that the Court appoint same. The attorneys for the parties are: Attorney for : Attorney for : 6 7 Name 8 9 10 Address 11 12 13 Telephone 14 15 16 17 18 DATED: 19 20 21 DATED: 22 23 24 25 26 The undersigned represents that this notice has been mailed to the Mediator and/or Alternate Mediator (as applicable), to all parties to the Matter, to their counsel, if any, and to the Mediation Program Administrator, and that a courtesy copy has Form 704 Name Firm Name Address City, State, Zip Code Telephone Firm Name City, State, Zip Code [Attach additional page(s) if necessary.] DATED: (Name of Party) (Name of Party's Counsel) DATED: (Name of Party) (Name of Party's Counsel) 3 Revised 11/09 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 been provided to the Judge, as required by the applicable provisions of Third Amended General Order No. 95-01. DATED: (Name of Party or Counsel) (Signature of Party/Counsel) cc: Hon. Barry Russell Mediation Program Administrator United States Bankruptcy Court 255 East Temple Street, Suite 1660 Los Angeles, California 90012 Form 704 4 Revised 11/09