NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk’s File Stamp ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: PLAINTIFF: DEFENDANT: NOTICE OF ADR NEUTRAL RECUSAL CASE NUMBER: YOU ARE HEREBY NOTIFIED THAT: I was assigned as the mediator arbitrator in this case on _____________________. I have determined myself to be disqualified and hereby withdraw from this case based on the grounds that I (or in the case of #1, 3, 4, 5, or 6, an immediate family member): 1. Have personal knowledge of disputed evidentiary facts.* 2. Served as a lawyer in this case or in another case involving the same issues or served as a lawyer for or gave advice to a party in this case. 3. Have a financial interest in the subject matter in this case or with a party to the dispute.* 4. Am a party to this case, or an officer, director, or trustee of a party.* 5. Have a familial relationship with an attorney in this case.* 6. Am in the private practice of law with a lawyer in this case.* 7. Believe my recusal would further the interests of justice. 8. Substantially doubt my capacity to be impartial or a person aware of the facts might reasonably entertain a doubt that I would be able to be impartial. 9. Have a permanent or temporary physical impairment preventing me from properly conducting the ADR process. 10. Am prevented from properly hearing the matter due to scheduling conflicts. 11. Believe my participation would jeopardize the integrity of the court or the mediation process. (Mediation only) Dated: _______________________________ . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) __ ___ ________________________________________ (SIGNATURE OF NEUTRAL) PROOF OF SERVICE BY MAIL I am over the age of 18 and not a party to this action. I am a resident of or employed in the county where the mailing occurred. My residence or business address is noted above. I served this Notice of ADR Neutral Recusal on the date noted below upon each party or counsel by depositing in the United States mail at __________________________________________, California, one copy of the original herein in a separate sealed envelope to each address as shown in the attached mailing list with postage thereon fully prepaid. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: _______________________________ . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) LAADR 077 New 04-07 LASC Approved __ ___ ________________________________________ (SIGNATURE OF DECLARANT) NOTICE OF ADR NEUTRAL RECUSAL American LegalNet, Inc. www.FormsWorkflow.com