CV-E-ARB-119 ARBITRATOR (Name, State Bar Number, and Address) State Bar No. FOR COURT USE ONLY TELEPHONE NO. EMAIL ADDRESS (Optional) FAX NO. (OPTIONAL) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO th STREET ADDRESS: 720 9 Street, Room 102 th MAILING ADDRESS: 720 9 Street, Room 102 CITY AND ZIP CODE: Sacramento, CA 95814 BRANCH NAME: Gordon D. Schaber PLAINTIFF: DEFENDANT: CASE NUMBER: QUALIFICATION STATEMENT ASSIGNED DEPARTMENT: It shall be the duty of the arbitrator to determine whether any cause exists for his/her disqualification in the case he/she is to hear upon any of the grounds set forth in Section 170 et seq. of Code of Civil Procedure governing the disqualification of judges. If any member of the arbitrator's law firm would be disqualified under subdivision 4 of Section 170 et seq., the arbitrator is disqualified. Unless the ground for disqualification is disclosed to the parties in writing and is expressly waived by all parties in writing, the arbitrator shall promptly notify the Arbitration Unit of any known ground for disqualification, and another arbitrator shall be selected as provided in rule 3.815 of the California Rules of Court. Arbitration services are not paid for by the court and are provided on a pro-bono basis. I attest that as a court appointed Arbitrator, I have not solicited and will not solicit any private mediation business from either party to this action. I certify that I have read the foregoing rule and I know of no cause for my disqualification. Executed on __________________, at ____________________, California Arbitrator CV-E-ARB-119 (Revised June 03, 2013) MANDATORY QUALIFICATION STATEMENT CIVIL Page 1 of 1 CRC 3.815/3.816 www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com