UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA 350 WEST FIRST STREET, SUITE 4311 LOS ANGELES, CALIFORNIA 90012 TEL: 213-894-2993 ADRCoordinator@cacd.uscourts.govREQUEST BY PANEL MEDIATOR TO INCUR COSTS IN EXCESS OF $50.00 Panel Member (Include address, phone and fax numbers, and social security or tax identification number):Case Title:Case Number:Total Costs Requested (Set forth the nature of the contemplated expenditures, the reason for the expenditures, the anticipated total amount and such other information as may be relevant for a determination that there is good cause for the expense to be incurred. If you are planning to request reimbursement for mileage, provide addresses and anticipated round-trip mileage. ): Name of Panel Mediator (Print) Signature of Panel MediatorDateGood cause having been found, authorization is granted to the Panel Mediator to incur the costs described above.Amount Approved: $ ADR Program Director Date 1If extra space is needed, attach additional sheets of paper. ADR-23 (07/18)REQUEST BY PANEL MEDIATOR TO INCUR COSTS IN EXCESS OF $50.00 1ADR PROGRAM American LegalNet, Inc. www.FormsWorkFlow.com