SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE MEDIATOR FEE STATEMENT This form is for members of the Civil Mediation Panel who provided a Court-Ordered Mediation pursuant to Local Rule, Title 3, Division 2. Please submit this form within ten (10) days of the mediation to the Coordinator of ADR Services: 4050 Main Street, Riverside, CA 92501; CourtADRDirector@riverside.courts.ca.gov RI-ADR07 SECTION A. MEDIATOR'S INFORMATION Mediator's Name: Email Address: Phone Number: THIS INFORMATION MUST MATCH THE INFORMATION ON YOUR VENDOR PAYEE FORM Make Check Payable to: Remit to Address: (ADDRESS) (CITY) (STATE) (ZIP CODE) SECTION B. MEDIATION INFORMATION Case Name: Date(s) of Mediation: Case No.: Length of Session(s): I certify that I was the mediator in the above-entitled case that was mediated pursuant to Local Rule Title 3, Division 2. I certify that at the time the mediation was held I was an active member of the Court's Civil Mediation Panel. As confirmation of my service: 1. Date Case Ordered to Court-Ordered Mediation: 2. Date Notice of Acceptance Filed: 3. Date Statement of Agreement/Non-Agreement Filed: I request payment of $150.00 for my services. SECTION C. MEDIATOR'S DECLARATION I declare under penalty of perjury the foregoing to be an accurate statement of services rendered in this case. (SIGNATURE OF CLAIMANT) (DATE) Fund: Cost Center: For Court Use Only 110001 335340 1220 939101 Date: PECT/Functional Area: GL: Approvers Initials: Approvers Printed Name: COMMENTS: Approved Fee: $150.00 Page 1 of 1 Adopted for Mandatory Use Riverside Superior Court RI-ADR07 [Rev. 09/09/2014] MEDIATOR FEE STATEMENT riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com