NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: PLAINTIFF: DEFENDANT: PEREMPTORY CHALLENGE OF ARBITRATOR CASE NUMBER: 1. I am a party (or attorney for a party) to this case. 2. The arbitrator , ____________________________, to whom the arbitration of this case is assigned is prejudiced against the party (or his or her attorney) or the interest of the party (or his or her attorney) so that declarant cannot or believes that he or she cannot have a fair and impartial hearing before the arbitrator. 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) __ ___ ________________________________________ (SIGNATURE OF DECLARANT) 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 Peremptory Challenge of Arbitrator on the date noted below upon each party or counsel and the arbitrator 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 below 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 079 New 04-07 LASC Approved __ ___ ________________________________________ (SIGNATURE OF DECLARANT) PEREMPTORY CHALLENGE OF ARBITRATOR Cal. Rules of Court, rule 3.855 American LegalNet, Inc. www.FormsWorkflow.com