ADR NEUTRAL (Name and address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF MERCED st 627 W. 21 , Street Merced, CA 95340 (209) 725-4111 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: EARLY MEDIATION PROGRAM (EMP) STATEMENT OF SETTLEMENT STATUS FORM (and REQUEST FOR PAYMENT) (Check one): UNLIMITED CASE (Amount demanded exceeds $25,000) LIMITED CASE (Amount demanded is $25,000 or less) CASE NUMBER: Assigned Judge: Case Category (please circle): I II III PLEASE NOTE: THIS FORM IS TO BE SENT OR FAXED TO THE ADR OFFICE (ONLY) WITHIN 5 DAYS OF THE CONCLUSION OF THE MEDIATION. DO NOT FILE THIS FORM WITH THE CIVIL CLERK'S OFFICE. Case Name: __________________________________________________________ Case Number: ______________________ Mediation took place on the following date(s): ______________________________ Mediation Proceedings lasted a total of _________ hours. Mediation resulted in: Full Agreement by all Parties Partial Agreement as to the following Parties: __________________________________________________ Non-Agreement REQUEST FOR PAYMENT As attested by my signature below, I mediated the above case as indicated above. As such, I request the Court forward the $300 stipend for my ADR Services rendered at the Mediation to my office above. Dated:_____________________ Signed:_________________________________________ Print Name: _____________________________________ Approved for Payment by Superior Court ADR Supervisor:__________________________________ [M-ADR3] [Rev. 2/13] EMP STATEMENT OF SETTLEMENT STATUS FORM American LegalNet, Inc. www.FormsWorkFlow.com