Attorney or Party Name, Address, Telephone & FAX Nos., State Bar No. & Email Address FOR COURT USE ONLY Attorney for UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA - **SELECT DIVISION** In re: CASE NO.: CHAPTER Debtor(s). ADVERSARY NO.: DIVISION REQUEST FOR ASSIGNMENT TO MEDIATION PROGRAM [NOTE: A COMPLETED ORDER ASSIGNING MATTER TO MEDIATION AND APPOINTING MEDIATOR AND ALTERNATE MEDIATOR MUST BE CONCURRENTLY UPLOADED THROUGH LODGED ORDER UPLOAD (LOU) WITH THIS REQUEST] [NO HEARING REQUIRED] Defendant. Plaintiff(s), vs. I hereby request that the following matter be assigned to the Bankruptcy Mediation Program of this district: Description of the Matter: 1. 2. Objection to claim/claim resolution Plan Objection to plan confirmation Plan formulation/negotiation 3. 4. May 2011 Valuation Preference This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. Page 1 F 701 5. 6. 7. Fraudulent transfer Lien avoidance Dischargeability Specify grounds: 8. Other. Please specify: Amount of money at issue in Matter: 1. 2. 3. 4. 5. 6. 7. 8. 9. $0 to $1,000 $1,001 to $10,000 $10,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1,000,001 to $5,000,000 $5,000,001 to $10,000,000 If more than $10,000,000, state amount: $ 10. Money not at issue. This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. May 2011 Page 2 F 701 SUBMITTED JOINTLY BY: Date: (Name of party) (Signature of party) Date: (Name of party's counsel) (Signature of party's counsel) Date: (Name of party) (Signature of party) Date: (Name of party's counsel) (Signature of party's counsel) Instructions from the court: A completed ORDER ASSIGNING MATTER TO MEDIATION PROGRAM AND APPOINTING MEDIATOR AND ALTERNATE MEDIATOR must be concurrently uploaded through Lodged Order Upload (LOU) with this Request for Assignment to Mediation Program. cc: Hon. Barry Russell Mediation Program Administrator United States Bankruptcy Court 255 East Temple Street, Suite 1660 Los Angeles, CA 90012 This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. May2011 Page 3 F 701 PROOF OF SERVICE OF DOCUMENT I am over the age of 18 and not a party to this bankruptcy case or adversary proceeding. My business address is: A true and correct copy of the foregoing document described as REQUEST FOR ASSIGNMENT TO MEDIATION PROGRAM will be served or was served (a) on the judge in chambers in the form and manner required by LBR 50052(d); and (b) in the manner indicated below: I. TO BE SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING (NEF): Pursuant to controlling General Order(s) and LBR, the foregoing document will be served by the court via NEF and hyperlink to the document. On , I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the email address(es) stated below: Service information continued on attached page II. SERVED BY UNITED STATES MAIL OR OVERNIGHT MAIL(indicate method for each person or entity served): , I served the following person(s) and/or entity(ies) at the last known address(es) in this On bankruptcy case or adversary proceeding by placing a true and correct copy thereof in a sealed envelope in the United States mail, first class, postage prepaid, and/or with an overnight mail service addressed as follows. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. Mediator: Alternate Mediator: Service information continued on attached page III. SERVED BY PERSONAL DELIVERY, FACSIMILE TRANSMISSION OR EMAIL (indicate method for each person or entity served): Pursuant to F.R.Civ.P. 5 and/or controlling LBR, on , I served the following person(s) and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method), by facsimile transmission and/or email as follows. Listing the judge here constitutes a declaration that personal delivery on the judge will be completed no later than 24 hours after the document is filed. Service information continued on attached page I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. Date:___________________________ Signature:_______________________________________ Printed Name:____________________________________ This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. May 2011 Page 4 F 701