ATTORNEY OR PARTY WITHOUT AN ATTORNEY TELEPHONE NO: ATTORNEY FOR (name, state bar number, and address) For Court Use Only FAX NO: (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF NEVADA 201 Church Street, Suite #5, Nevada City, CA 95959 10075 Levon Avenue, Suite #301, Truckee, CA 96161 (530)265-1294 (530)582-7835 Plaintiff/ Petitioner: Defendant:/ Respondent: Case Number STIPULATION AND ORDER TO PARTICIPATE IN ADR Pursuant to CRC §3.221, all parties stipulate to participate in mediation of this case. Any ADR Services shall be paid for by the parties pursuant to a separate ADR Fee Agreement. The parties further stipulate:  That be appointed as the mediator. Address: City, State, Zip: Phone Number: It is understood that the ADR Information Form must be submitted by the parties and counsel at the conclusion of the case. Attorney(s) signing on behalf of their client(s) have been given the authority to stipulate to mediation. ___________________ ___________________________________ ___________________________________ Date Type or Print Name Signature of Party or Attorney for Party ___________________ ___________________________________ ___________________________________ Date Type or Print Name Signature of Party or Attorney for Party ___________________ ___________________________________ ___________________________________ Date Type or Print Name Signature of Party or Attorney for Party ___________________ ___________________________________ ___________________________________ Date Type or Print Name Signature of Party or Attorney for Party APPROVED; Mediation to be completed by Mandatory Settlement Conference Date: _______________________________ DATED: _____________________________________ JUDGE OF THE SUPERIOR COURT American LegalNet, Inc. www.FormsWorkFlow.com