ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR # 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 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: CASE NUMBER: MEDIATION STATEMENT ASSIGNED DEPT: A CASE MANAGEMENT CONFERENCE is scheduled as follows: Date: Time: Dept.: Address of court (if different from the address above): INSTRUCTIONS: All applicable boxes must be checked, and the specified information must be provided. All parties have considered Mediation as a means to resolving this case and have agreed: Mediation is appropriate for this case. Parties have submitted a Stipulation and Order for Mediation form or will submit a Stipulation within 14 days following the Case Management Conference. Mediation is not appropriate for this case for the following reasons: I am completely familiar with this case and will be fully prepared to discuss the status of discovery and Alternative Dispute Resolution (ADR), as well as other issues raised by this statement, and will possess the authority to enter into stipulation on these issues at the time of the Case Management Conference, including the written authority of the party where required. Date: ______________________ _____________________________________________ (Type or Print Name) ___________________________________________ (Signature of Party or Attorney) _____________________________________________ (Type or Print Name) ___________________________________________ (Signature of Party or Attorney) Mediation Statement CV\E­MED­172 (Rev 02.13.09) Local Form Adopted for Mandatory Use American LegalNet, Inc. www.FormsWorkFlow.com