NAME AND ADDRESS OF ATTORNEY: FOR COURT USE ONLY TELEPHONE NUMBER: SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 220 Main Street, Brawley, CA 92227 415 East Fourth Street, Calexico, CA 92231 939 West Main Street, El Centro, CA 92243 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: ARBITRATOR'S FEE STATEMENT CASE NUMBER: Pursuant to California Rules of Court, rule 3.819 and Local Rules ­ Superior Court of California, County of Imperial, rule 3.5.6, the following fee(s) are requested for conducting arbitration proceedings in the above named case. Date session concluded: _________________ Date Award/Settlement filed with Court:_______________ Name of Arbitrator: _______________________ Name of Payee: __________________________ Address of Payee: ______________________ Length of Session: _______________________ Fee(s) Requested:________________________ ______________________ ______________________ Social Security number or Taxpayer Identification number: ______________________________ I declare under penalty of perjury, under the laws of the State of California that the foregoing is true and correct. Date: ___________________ Signature of Arbitrator: ______________________________ FOR COURT USE ONLY Amount authorized _____________ Date: ____________________ ____________________________________ (ARBITRATION ADMINISTRATOR) Form Adopted for Mandatory Use CV-01 (Adopted 01/01/12, Revised 01/01/13) ARBITRATOR'S FEE STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com