ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): FOR COURT USE ONLY TELEPHONE NO. FAX NO. (Optional) EMAIL ADDRESS (Optional) ATTORNEY FOR (NAME): Superior Court of California, County of Sacramento 720 Ninth Street, Room 101 Sacramento, CA 95814-1380 (916) 874-5522—Website www.saccourt.ca.gov SETTLEMENT CONFERENCE DATE: PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: DECLARATION AND REQUEST FOR EXEMPTION FROM MANDATORY SETTLEMENT CONFERENCE PROGRAM (Local Rule 12.20) CASE NUMBER: Having participated in Mediation pursuant to Local Rule 12.14, the following party requests that the above-entitled matter be exempted from the Mandatory Settlement Conference Program: REQUESTING PARTY TYPE/NAME: _____________________________________________________________________ DATE OF MEDIATION: _______________________________________________________________________________ Court Mediation TYPE OF MEDIATION: Private Mediation MEDIATOR: ________________________________________________________________________________________ ORDER The foregoing Declaration having been read and considered, and good cause appearing: The Court vacates the scheduled Mandatory Settlement Conference. The Court orders that no Mandatory Settlement Conference shall be scheduled in this matter. Request for exemption from the Mandatory Settlement Conference Program is denied. It is further ordered that: ________________________________________________________________________________ _____________________________________________________________________________________________________ Dated: ______________________________ Signed: __________________________________________________________ Judge of the Superior Court Declaration and Request for Exemption from Mandatory Settlement Conference Program (Local Rule 12.20) CV\E–MED–170 (Rev 02.13.09) Local Form Adopted for Mandatory Use American LegalNet, Inc. www.FormsWorkflow.com