PKT-037 (Rev. ) SUPERIOR COURT OF CALIFORNIA COUNTY OF SAN DIEGO PROBATE MEDIATOR PACKET FORMS INCLUDED IN THIS PACKET Probate Mediator Instructions SDSC Form #PR-152 INST Probate Mediator Profile SDSC Form #PR-152 Probate Mediator Certification and Release of Liability SDSC Form #PR-152 A American LegalNet, Inc. www.FormsWorkFlow.com SDSC PR - 152 INST ( Rev. 12/17 ) PROBATE MEDIATOR INSTRUCTIONS Informational Form SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO PROBATE MEDIATOR INSTRUCTIONS By submitting a completed Probate Mediator Profile (SDSC Form # PR - 15 2 ) and a Probate Mediator Certification and Release of Liability form (SDSC Form # PR - 15 2A ) as inst ructed below : You are requesting that a two - page Probate Mediator Profile containing your contact information and mediator profile information be included in binders at various court locations to be made available to litigants by the San Diego Superior Co urt, Probate Division, pursuant to Cal. Rules of Court, rule 10.781. Your Probate Mediator Certification and Release of Liability form will not be included in the binders, but will be kept on file by the court. You are releasing the Superior Court of Cali fornia, County of San Diego and its employees, agents, and assigns from any liability or damage which may result from furnishing any of the information displayed in your profile or requested in the certification. You are agreeing to serve as a mediator on a pro bono basis for at least one case per year, not to exceed eight hours. N ote: Your profile may be temporarily or permanently removed from the binders at any time at the sole discretion of the court without cause and without notice to you. If you fail to submit a completed Probate Mediator Profile and Probate Mediator Certification and Release of Liability form on a bi - annual basis, your profile will be removed from the binders without notice. SUBMISSION INSTRUCTIONS: A. Email a c omplete d Prob ate Mediator Packe t (SDSC PKT - 037), which includes a Probate Mediator Profile (SDSC Form # PR - 15 2) , and Probate Mediator Certification and Release of Liability form (SDSC Form #PR - 15 2A ) to Probate.ProTems @sdcourt.ca.gov . OR B. Mail a c omplete d Probate Mediator Packet (SDSC PKT - 037), which includes a Probate Mediator Profile (SDSC Form #PR - 152) , and Probate Mediator Certification and Release of Liability form (SDSC Form #PR - 152A) to: San Diego Superio r Court Attn: Probate Division 1100 Union St. San Diego, CA 92101 American LegalNet, Inc. www.FormsWorkFlow.com SDSC PR-152 (New 4/10) PROBATE MEDIATOR PROFILE Page 1 of 2 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO PROBATE MEDIATOR PROFILE DISCLAIMER: THE INFORMATION CONTAINED WITHIN THIS MEDIATOR PROFILE HAS BEEN PROVIDED BY THE MEDIATOR. THE SAN DIEGO SUPERIOR COURT DOES NOT GUARANTEE OR WARRANT THE CONTENT OR ACCURACY OF THE INFORMATION, OR THE COMPETENCY OR QUALIFICATIONS OF THE MEDIATOR. I. CONTACT INFORMATION: Mediator Name: Organization/Firm/Company: Address: Telephone Number: Fax Number: Email/Website: II. EDUCATION / SPECIALIZATION: Describe your relevant education and specialization(s) (specify the name(s) and location(s) of the institution(s) attended, the dates of attendance, and the specific degree(s) and/or certifications conferred): Education/Specialization: Probate, Trust, and Estate Planning Education, and Other Relevant Education: III. PROBATE AND OTHER RELEVANT EXPERIENCE: Describe your probate and other relevant experience (for each legal practice or employer, specify the relevant dates, practice/employer name and location, and the specific practice areas and/or types of relevant experience such as real estate or tax): Last updated: American LegalNet, Inc. www.FormsWorkFlow.com SDSC PR-152 (New 4/10) PROBATE MEDIATOR PROFILE Page 2 of 2 IV. MEDIATION TRAINING: Describe your mediation training (specify the name(s) and location(s) of the training provider(s), the dates of the training(s), the number of hours of classroom training, experiential training, and specialized training): V. MEDIATION EXPERIENCE / STYLE: Number of probate mediations conducted: Number of other mediations conducted: Description of mediation experience and style: Additional ADR experience (e.g., experience as an arbitrator, settlement conference officer, neutral evaluator): VI. MEDIATOR FEE INFORMATION: Hourly rate: $ Cancellation Policy: Deposit Policy: Additional Policies or Fees: VII. LANGUAGE CAPABILITIES OF MEDIATOR: American LegalNet, Inc. www.FormsWorkFlow.com SDSC PR-152 A (Rev. 6/12) PROBATE MEDIATOR CERTIFICATION AND RELEASE OF LIABILITY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO PROBATE MEDIATOR CERTIFICATION AND RELEASE OF LIABILITY PROBATE MEDIATOR CERTIFICATION I certify as follows: (Type or Print Name) 1. I request that my Probate Mediator Profile information be included in binders at various court locations to be made available to litigants by the San Diego Superior Court, Probate Division, pursuant to Cal. Rules of Court, rule 10.781 (hereinafter 223List224). I understand that this Probate Mediator Certification and Release of Liability Form will be maintained by the court and will not be contained in the binders. 2. I agree that inclusion of my Probate Mediator Profile is a privilege which is revocable and confers no rights upon me. I understand that I serve at the pleasure of the court and may be temporarily or permanently removed from the binders at any time at the sole discretion of the court without cause. 3. I agree that if I fail to submit a completed Mediator Profile and updated Probate Mediator Certification on a bi-annual basis, my Mediator Profile will be removed from the binders. I accept the responsibility for providing updated Profile information and to provide written notice if I no longer wish to be included on the List. 4. I agree to comply with all applicable statutes, California Rules of Court, local court rules and all applicable ethics requirements, including but not limited to Cal. Rules of Court, rule 10.781, Evidence Code section 703.5, and Evidence Code sections 1115 et seq. 5. I agree to serve as a mediator on a pro bono basis for at least one case a year, not to exceed eight hours. 6. I am in good standing in California and in each state in which I am licensed to practice law. 7. I have never been disciplined by the State Bar of California, a bar association, a public disciplinary or professional licensing agency or any ADR organization or entity in any state or by any court of record. 8. I have never been declared a vexatious litigant. 9. There are no felony charges pending against me. 10. I have never been convicted of or pleaded no contest to a felony. 11. I have never been convicted of or pleaded no contest to a misdemeanor involving moral turpitude. 12. There has never been an entry of judgment against me in any civil action for actual fraud or punitive damages. I certify under penalty of perjury under the laws of the State of California that the foregoing statements are true and correct. Date: Signature of Mediator RELEASE OF LIABILITY I hereby release the Superior Court of California, county of San Diego and its employees, agents, and assigns from any liability or damage which may result from furnishing any of the information requested in the Probate Mediator Profile and Probate Mediator Certification. Date: Type or print name of Mediator Signature of Mediator American LegalNet, Inc. www.FormsWorkFlow.com