ADR NEUTRAL NAME, ADDRESS, TELEPHONE, FAX AND EMAIL: PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: ACKNOWLEDGMENT OF CONFIDENTIALITY MEDIATION SESSION (DO NOT FILE WITH THE COURT) CASE NUMBER: This form is provided to offer mediators a convenient means to inform participants of the applicable ethical and other rules. The participants in the mediation proceeding of this case agree that: 1. The mediation proceeding will be confidential, in accordance with California Evidence Code sections 703.5 and 1115 through 1128. 2. This agreement does not affect the admissibility of a written settlement agreement reached as a result of this mediation proceeding in an action to enforce that settlement. 3. This agreement will not preclude a report of information to the ADR Administrator or an inquiry by the Administrator regarding complaints against a neutral pursuant to California Rules of Court, rules 3.850 through 3.863. Dated:___________________________ ____________________________________________________ Neutral ____________________________________________________ Party ____________________________________________________ Attorney _______________________________________________________ Party _______________________________________________________ Attorney _______________________________________________________ Party _______________________________________________________ Attorney ____________________________________________________ Party ____________________________________________________ Attorney _______________________________________________________ Other Participant _______________________________________________________ Title _______________________________________________________ Representing (specify party) Additional pages attached (number) _______ ____________________________________________________ Other Participant ____________________________________________________ Title ____________________________________________________ Representing (specify party) ACKNOWLEDGMENT OF CONFIDENTIALITY � MEDIATION SESSION Adopted for Mandatory Use L2754 (New February 2008) EC �703, 1115, et seq, CCP �1175.10 California Rules of Court rule 3.850 et seq American LegalNet, Inc. www.FormsWorkflow.com