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 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: MEDIATOR’S FEE STATEMENT and ORDER FOR REIMBURSEMENT CASE NUMBER: Pursuant to Local Rule 12.24, I hereby submit my request for payment of Mediator’s fees in the above matter in the amount of $200 for up to 3 hours of Mediation time. I declare that I was duly appointed and served as Mediator, that I fully performed all official responsibilities herein, and that I am in good standing with the California State Bar. INSTRUCTIONS: Please file this form with the court within 10 calendar days of the final Mediation date. VENDOR ID NUMBER: ____________________________ MEDIATION DATE(S): ____________________________ STATEMENT OF AGREEMENT/NONAGREEMENT DATE: ____________________________ TOTAL HOURS IN SESSION: ____________________________ MEDIATION DID NOT OCCUR, BUT FEES ARE BEING REQUESTED PER LOCAL RULE 12.24: (supply specific cause): _____________________________________________________________________________ _____________________________________________________________________________ I hereby affirm that the above-entitled information is true and correct; that I have completed all official duties required and have filed the required documents; and that the requested Mediator’s fee is in accordance with Local Rules. ___________________________________________________________ Date: _______________________ (Signature of Mediator) For Court Use Only As defined in the Local Rules; the Mediation fee of $200 is approved for payment on: ________________________________________ Claim Date: _________________________ Claim Number: ____________________________________________________ ADR Administrator / Representative: ______________________________________________________________________________ ORDER Pursuant to Local Rule 12.24, the Mediation fee of $200 is ordered to be reimbursed to the Court within 10 calendar days of the date of this order by: ___________________________________________________________________________________________ Party Name(s) Dated: _________________________ Signed: _____________________________________________________________________ Judge of the Superior Court Mediator’s Fee Statement and Order for Reimbursement CV\E–MED–174 (Rev 02.13.09) Local Form Adopted for Mandatory Use Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com