CSD 4003 [03/26/99] -DO NOT FILE WITH THE COURT-THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT- UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA In re: Debtor: Plaintiff(s): Defendants: Case No. Adversary Proceeding No. CASE QUESTIONNAIRE IN CONNECTION WITH MEDIATION PROCEDURE -INSTRUCTIONS1. The purpose of this case questionnaire is to help the parties settle their differences and reduce expense, making mediation a meaningful and effective procedure. 2. Upon the parties receiving notification of the appointment of a mediator and receiving notice of the date, time and place of the mediation conference, each party shall simultaneously prepare and serve upon all other parties and the mediator, a completed questionnaire in accordance with this form. YOU WILL NOT FILE THE CASE QUESTIONNAIRE OR COPIES THEREOF WITH THE COURT. THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT, NOR IS IT INTENDED TO MODIFY OR AMPLIFY THE EXISTING PLEADINGS. THE PARTIES' GOOD FAITH COMPLIANCE WITH THE LETTER AND SPIRIT OF THE RULE REGARDING MEDIATION REQUIRES A CONSCIENTIOUS AND COMPLETE DISCLOSURE OF INFORMATION AND POSITIONS. PLEASE COMPLETE THE QUESTIONNAIRE WITH THESE PRINCIPLES IN MIND. 3. a. b. c. ALL QUESTIONS REFER TO THE INCIDENT OR AGREEMENT IN THIS ADVERSARY PROCEEDING ONLY. Answer each question. If a question is not applicable, answer "N/A." Your answers are not limited to your personal knowledge, but you are required to furnish all information available to you or anyone acting on your behalf, whether you are a plaintiff, defendant, cross-complainant or cross-defendant. Type or legibly print your answer below each question. If you cannot completely answer a question in the space provided on the case questionnaire, identify and repeat the question in full on an attachment followed by your answer. Do not put part of an answer on the case questionnaire and part on the attachment. You may put more than one answer on each attached page. TO ASSIST THE MEDIATOR AND YOURSELF, THIS FORM MAY BE REPRODUCED IN ITS ENTIRETY ON YOUR OWN WORD PROCESSING EQUIPMENT. When you have completed the case questionnaire, sign the verification and serve the original upon the mediator with copies to all other parties. Failure to complete the case questionnaire fully and in compliance with the stated purpose (see paragraph 2 above) shall be reported by the mediator to the Court and may be grounds for the imposition of sanctions. DO NOT FILE THIS CASE QUESTIONNAIRE WITH THE COURT. d. e. f. g. CSD 4003 -i2001 © American LegalNet, Inc. CSD 4003 [03/26/99] -DO NOT FILE WITH THE COURTUNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA In re: Debtor: Plaintiff(s): Defendant(s): Case No. Adversary Proceeding No. -QUESTIONS1. FOR ALL CASES. a. State your name and street address. b. State your current business name and street address, type of business entity and your title. c. Describe in detail your claim or defenses and the facts on which they are based, giving relevant dates. CSD 4003 -12001 © American LegalNet, Inc. CSD 4003 [03/26/99] d. State the name, street address and telephone number of each person who has knowledge of facts relating to this lawsuit and specify the person's area of knowledge. e. Describe each document or photograph that relates to the issues and facts. You are encouraged to attach a copy of each. For each that you have described but not attached, state the name, street address and telephone number of each person who has it. CSD 4003 -22001 © American LegalNet, Inc. CSD 4003 [03/26/99] 2. FOR CLAIMS ARISING FROM TORT (INJURY TO PERSON OR PROPERTY). 11 U.S.C. §523(a)(6). a. Describe in detail all damages to the person for which you claim compensation including, but not limited to, injury or illness, medical and related expenses and loss of income. b. Itemize your property damage with attention to the market value of the item damaged and the cost of replacement or repair. State the amount as to each item and where practicable submit a copy of an itemized bill or estimate. CSD 4003 -32001 © American LegalNet, Inc. CSD 4003 [03/26/99] 3. FOR CASES BASED UPON AGREEMENTS. a. In addition to your answer to 1.e., state all the terms and give the date of any part of the agreement that is not in writing. b. Describe each item of damage or cost you claim, state the amount and show how it is computed. CSD 4003 -4- 2001 © American LegalNet, Inc. CSD 4003 [03/26/99] 4. FOR CASES ARISING UNDER THE PROVISIONS OF TITLE 11. a. Please list the Bankruptcy Code section(s) which you rely upon for recovery or defense. b. State briefly the relation between the Code section(s) and the facts which you assert. I declare under penalty of perjury that the foregoing answers are true and correct under the laws of the State of California. Executed this day of , , at . (Typed Name and Signature) (Address) (City, State, ZIP Code) CSD 4003 -52001 © American LegalNet, Inc.