ADR PANEL MEMBER: (Name and Address): FOR COURT USE ONLY TELEPHONE NO: E-MAIL ADDRESS (Optional): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF CONTRA COSTA MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CASE NAME: P.O. BOX 911 MARTINEZ, CA 94553 MARTINEZ NOTICE OF DATE, TIME AND PLACE OF MEDIATION CASE NUMBER: All parties in this case are notified this matter is set for mediation on: Date: Time: Place: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ I ______________________________________ declare, under penalty of perjury, that all counsel and parties have been notified of the date, time and place of the mediation. Date: _________________________ Signature: __________________________________________ Print Name: _________________________________________ Complete this form and email to adrweb@contracosta.courts.ca.gov, Fax (925) 957-5689 or mail: ADR Program, P.O. BOX 911, Martinez, CA 94553 ADR-301 Rev. 8/2/16 American LegalNet, Inc. www.FormsWorkFlow.com