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: REQUEST FOR DISQUALIFICATION OF ADR NEUTRAL CASE NUMBER: INSTRUCTIONS: 1. Complete this form. 2. Attach a verified statement of the facts constituting the grounds for disqualification. Mere conclusions are insufficient. 3. Present at the earliest opportunity after discovery of the facts constituting the grounds for disqualification. 4. Serve copies of the statement on each party or his or her attorney who has appeared and on the neutral. 5. Submit original to the ADR clerk. I HEREBY DECLARE THAT: __________________________________________ (neutral name) was assigned as the mediator arbitrator in this case on __________________. I have demanded that the neutral disqualify himself/herself. The neutral has failed to do so. I object to the ADR process before this person on grounds that the person (or in the case of #1, 3, 4, 5, or 6, an immediate family member): 1. Has 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 the present case. 3. Has a financial interest in the subject matter in this case or with a party to the dispute. 4. Is a party to this case, or an officer, director, or trustee of a party. 5. Has a familial relationship with an attorney in this case. 6. Is in the private practice of law with a lawyer in this case. 7. Believe his/her recusal would further the interests of justice. 8. Substantially doubt his/her capacity to be impartial or a person aware of the facts might reasonably entertain a doubt that he/she would be able to be impartial. 9. Has a permanent or temporary physical impairment preventing him/her from properly conducting the ADR process. 10. Believe his/her participation would jeopardize the integrity of the court or the mediation process. (Mediation only) 11. Other (specify): ___________________________________________________________________________________ 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 078 New 04-07 LASC Approved ___ ________________________________________ (SIGNATURE OF DECLARANT) REQUEST FOR DISQUALIFICATION OF ADR NEUTRAL CCP 170.3, CCP 1141.18, CRC 3.816, CRC 3.855, LASC 12.6 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Short Title Case Number 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 Request for Disqualification of ADR Neutral on the date noted below upon each party or counsel and the ADR neutral 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) ___ ________________________________________ (SIGNATURE OF DECLARANT) RESPONSE TO REQUEST FOR DISQUALIFICATION OF ADR NEUTRAL I consent to the disqualification. I do not consent to the disqualification. 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 Response to Request for Disqualification of ADR Neutral on the date noted below upon each party or counsel by depositing in the United States mail at _______________________________, California, below in the attached mailing list with one copy of the original herein in a separate sealed envelope to each address as shown 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 078 New 04-07 ___ ________________________________________ (SIGNATURE OF DECLARANT) REQUEST FOR DISQUALIFICATION OF ADR NEUTRAL CCP 170.3, CCP 1141.18, CRC 3.816, CRC 3.855, LASC 12.6 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com