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 FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES INCURRED BY PANEL MEDIATORName of Payee (Include address, phone and fax numbers, and social security or tax identification number):Case Title:Case Number:Date of Mediation (If no mediation held, insert filing date of Mediation Report (Form ADR-03).):Total Requested for Reimbursement (Set forth the nature, reason and amount of each expenditure supported by actual receipts or copies thereof. If requesting reimbursement for mileage, state addresses driven to and from, and round-trip mileage. If applicable, include the signed Request By Panel Mediator to Incur Costs in Excess of $50.00 form(s). ): Name of Panel Mediator (Print) Signature of Panel Mediator DateAPPROVED FOR PAYMENT with funds from the Central District220s Attorney Admissions Fund as provided for in the United States District Court Central District of California Policy for Reimbursement of Out-of-Pocket Expenses Incurred byPanel Mediators. Amount Approved: $ ADR Program DirectorDate 1If extra space is needed, attach additional sheets of paper.1 REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES INCURRED BY PANEL MEDIATORADR-24 (07/18)ADR PROGRAM American LegalNet, Inc. www.FormsWorkFlow.com