Arbitrator Name and Address: Telephone No.: E-Mail Address (Optional): Fax No. (Optional): JUSTICE CENTER Central - 700 Civic Center Dr. West, Santa Ana, CA 92701-4045 Harbor - Newport Beach Facility - 4601 Jamboree Rd, Newport Beach, CA 92660-2895 North - 1275 N. Berkeley Ave., P. O. Box 5000, Fullerton, CA 92838-0500 West - 8141 13th Street, Westminster, CA 92683-4593 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE ARBITRATOR'S FEE STATEMENT CASE NUMBER: Pursuant to California Rul es of Court, rule 3.819 a nd Local Rules - Superior Court of California, County of Orange, rule 360, the following fee(s) are requested for conducting arbitration proceedings in the above-named case. (Attach a declaration to support payment of fees if the case settled at the hearing, no hearing was conducted or extraordinary fees are requested.) Date session concluded: Name of Arbitrator: Name of Payee: Address of Payee: Date Award or Settlement filed with the Court: Fee(s) Requested Fee for entire session: Extraordin ary fees: TOTAL: $ 150.00 Last four digits of your Social Security # or your full Taxpayer Identification #: A current signed IRS Form W-9 or Payee Data Records is: attached has been submitted to the Court I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Signature of Arbitrator: (For Clerk's Use Only) Amount approved: $ Authorization __________________________________________ , Clerk of the Court By: Deputy Clerk (For Accounting Services Use Only) Account Coding G/L Acct. 939102 Cost/Fund Center 306311 WBS Element Functional Area PCT 1220 Fund 110001 Accounting Services Approval Date: Authorized By: Tax Code Amount Review and Authorization Date: By: Approved for Optional Use L-0190 (Rev. 201 ) ARBITRATOR'S FEE STATEMENT California Rules of Court, rule 3.819 American LegalNet, Inc. www.FormsWorkFlow.com