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ADR Case Referral Intake Form. This is a California form and can be use in Los Angeles Local County.
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Tags: ADR Case Referral Intake Form, ADR 039, California Local County, Los Angeles
Superior Court of California, County of Los Angeles
JOHN A. CLARKE, EXECUTIVE OFFICER/CLERK
ALTERNATIVE DISPUTE RESOLUTION (ADR)
ADR CASE REFERRAL INTAKE
(Please type or print clearly)
CASE INFORMATION
Case Number:
Courthouse:
Dept.:
Case Name:
Litigation Type:
ADR Process:
Civil
MEDIATION
Family Law
Probate
ARBITRATION
Other (specify): _________________________________________________
NEUTRAL EVALUATION
Case Type: See Page 2
SETTLEMENT CONFERENCE
ADR Completion Date:
Amount in Dispute:
Plaintiff/Petitioner or attorney:
$0-$25,000
$50,000-$100,000
$250,000-$500,000
$750,000-$1,000,000
$25,000-$50,000
$100,000-$250,000
$500,000-$750,000
Over $1,000,000
---------------------------------------------------------------------------------------------------$0-$25,000
$50,000-$100,000
$250,000-$500,000
$750,000-$1,000,000
Defendant/Respondent or attorney:
$25,000-$50,000
$100,000-$250,000
$500,000-$750,000
Over $1,000,000
NEUTRAL SELECTION
Party Select Panel:
The parties select the following Neutrals in order of preference from the Court ADR Party Pay Panel and acknowledge they are undertaking a
financial commitment in selecting a Party Pay Panel Neutral.
1) NAME: ___________________________________________________________
NEUTRAL NO.: ____________________________
2) NAME: ___________________________________________________________
NEUTRAL NO.: ____________________________
_____________________________________________________________
(signature of plaintiff/petitioner or attorney)
_____________________________________________________________
(signature of defendant/respondent or attorney)
ADDITIONAL SIGNATURES LISTED ON ATTACHED PAGE
Random Select Panel:
The parties understand that a Neutral from the Court ADR Pro Bono Panel will be assigned on a random basis (civil mediation and arbitration only).
NAME OF ASSIGNED NEUTRAL: ___________________________________________________________
NEUTRAL NO.: ____________________________
PARTIES
ATTORNEY NAME:
ATTORNEY NAME:
FIRM:
FIRM:
ADDRESS:
ADDRESS:
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
E-MAIL:
E-MAIL:
ATTORNEY FOR:
ATTORNEY FOR:
___________________________________________________________________
(party name)
(party type)
____________________________________________________________________
(party name)
(party type)
ATTORNEY NAME:
ATTORNEY NAME:
FIRM:
FIRM:
ADDRESS:
ADDRESS:
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
CITY:
PHONE: (
STATE:
)
E-MAIL:
)
E-MAIL:
ATTORNEY FOR:
FAX: (
ZIP:
ATTORNEY FOR:
___________________________________________________________________
____________________________________________________________________
(party name)
(party type)
(party name)
(party type)
ADDITIONAL PARTIES LISTED ON PAGE THREE
FOR OFFICE USE ONLY
Received by: ________________________________ ___________________________
Name
Date
LAADR 039 (Rev. 04/09)
LASC Approval 10-04
Case Mgr Assigned: ________________________________ _____________________
Name
Date
Page 1 of 3
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ADR CASE REFERRAL INTAKE
(continued)
Case Name:
Case Number:
CASE SELECTION CRITERIA
CASE TYPE
Antitrust/Trade Regulation
Auto Tort - Personal Injury/Property Damage/Wrongful Death (PI/PD/WD)
Auto Tort - Uninsured Motorist - PI/PD/WD
Civil Harassment
Construction Defect
Contract - Breach of Rental/Lease Contract (not insurance, UD, or wrongful eviction)
Contract - Collections
Contract - Contract/Warranty Breach - Seller Plaintiff (not insurance, fraud, or negligence)
Contract - Contractual Fraud
Contract - Insurance Coverage/Subrogation
Contract - Negligent Breach of Contract/Warranty (not insurance or fraud)
Contract - Other Breach of Contract/Warranty (not insurance, fraud, or negligence)
Contract - Tortious Interference
Declaratory Relief Only
Elder/Dependent Adult Abuse
Employment - Labor Commissioner Appeals
Employment - Other (not wrongful termination or labor commissioner appeal)
Employment - Wrongful Termination
Family
Injunctive Relief Only (not domestic/harassment)
Non-PI/PD/WD Tort - Business/Commercial Tort (not fraud or breach of contract)
Non-PI/PD/WD Tort - Civil Rights (e.g., discrimination, false arrest)
Non-PI/PD/WD Tort - Defamation (e.g., slander, libel)
Non-PI/PD/WD Tort - Fraud (no contract)
Non-PI/PD/WD Tort - Intellectual Property
Non-PI/PD/WD Tort - Legal Malpractice
Other PI/PD/WD Tort - Asbestos
Other PI/PD/WD Tort - Intentional (e.g., assault, vandalism, etc.)
Other PI/PD/WD Tort - Intentional Infliction of Emotional Distress
Other PI/PD/WD Tort - Medical Malpractice
Other PI/PD/WD Tort - Premises Liability
Other PI/PD/WD Tort - Product Liability (not asbestos, toxic/environmental)
Partnership & Corporate Governance
Probate
Real Property - Eminent Domain/Condemnation
Real Property - Mortgage Foreclosure
Real Property - Quiet Title
Real Property - Wrongful Eviction
Real Property - Other
Securities
Toxic Tort/Environmental
Workplace Harassment
Writ of Mandate
Do you need a neutral who accepts cases on short notice?
Jurisdiction Type:
Unlimited
Yes
No
Limited
Language ability needed other than English:
ADA Accommodations
Accessible parking
Accessible elevators
Accessible public phones
Accessible tables/counters
Location: Zip Code:
LAADR 039 (Rev. 04/09)
LASC Approval 10-04
Accessible entrance
Accessible restrooms
Accessible listening devices
Other (specify):
City:
Page 2 of 3
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ADR CASE REFERRAL INTAKE
(continued)
(This Form Must Be Completed In Detail)
Case Name:
Case Number:
ADDITIONAL PARTIES
ATTORNEY NAME:
ATTORNEY NAME:
FIRM:
FIRM:
ADDRESS:
ADDRESS:
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
E-MAIL:
E-MAIL:
ATTORNEY FOR:
ATTORNEY FOR:
___________________________________________________________________
(party name)
(party type)
___________________________________________________________________
(party name)
(party type)
ATTORNEY NAME:
ATTORNEY NAME:
FIRM:
FIRM:
ADDRESS:
ADDRESS:
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
E-MAIL:
E-MAIL:
ATTORNEY FOR:
ATTORNEY FOR:
___________________________________________________________________
(party name)
(party type)
___________________________________________________________________
(party name)
(party type)
ATTORNEY NAME:
ATTORNEY NAME:
FIRM:
FIRM:
ADDRESS:
ADDRESS:
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
E-MAIL:
E-MAIL:
ATTORNEY FOR:
ATTORNEY FOR:
___________________________________________________________________
(party name)
(party type)
___________________________________________________________________
(party name)
(party type)
ATTORNEY NAME:
ATTORNEY NAME:
FIRM:
FIRM:
ADDRESS:
ADDRESS:
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
CITY:
PHONE: (
STATE:
)
FAX: (
ZIP:
)
E-MAIL:
E-MAIL:
ATTORNEY FOR:
ATTORNEY FOR:
___________________________________________________________________
(party name)
(party type)
___________________________________________________________________
(party name)
(party type)
To obtain additional case information, visit Case Summaries at www.lasuperiorcourt.org
LAADR 039 (Rev. 04/09)
LASC Approval 10-04
Page 3 of 3
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