Superior Court of California, County of Humboldt Appendix 8.26(a) Local Form CCV-8.5 FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number & address): TELEPHONE NO.: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF HUMBOLDT 825 Fifth Street Eureka, CA 95501 FAX NO. (Optional): PETITIONER: RESPONDENT: CLAIMANT: CASE NUMBER: EX-PARTE REQUEST AND ORDER RE: DISQUALIFICATION OF MEDIATOR OR EVALUATOR 1. I am the Petitioner in the action. Respondent Other (affiliation with case): 2. I move to disqualify (name of mediator or evaluator) as Mediator or Evaluator in the matter herein for the following reasons: to act a. Conflict of Interest. (Please state all facts which support this claim. You may attach additional pages as needed). b. Other. (Please state all facts which support this claim. You may attach additional pages as needed). 138 American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California, County of Humboldt Matter of: Case No.: ______ ORDER The Court hereby: Denies the Order requested: Grants the Order requested: IT IS SO ORDERED. ____________________________________ Judicial Officer of the Superior Court PROOF OF SERVICE BY MAIL On ___/___/________, I served the above Ex-Parte Request and Order Re: Disqualification of Mediator or Evaluator by depositing a copy thereof, enclosed in a sealed envelope, with postage prepaid, in the United States mail to the following parties and/or their attorney of record at the following addresses: At the time of service, I was at least 18 years of age and NOT a party to the action. My address is: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and this declaration is executed on (insert date) , at (insert city) , California. ___________________________________ Print Name _______________________________________ Signature Adopted for Optional Use Ex-Parte Req & Order re DQ of Med or Eval Form CCV-8.5, Eff. 07/01/13 139 American LegalNet, Inc. www.FormsWorkFlow.com