001001001001001002003004005006007b006001tb003006n001b013001tfr007013b006016007f017001tb003016n020001b013001002f016001021fn005b001021003rn007001b004n007b016001f022006001004006b023005tn001024frr001b013001023003002n007t005001f016022001006005tb006022002001025026026001tb003016n020001t005016n005006001006005022027bb022001t007n020017001tfr007013b006016007f001030025026031032001 Tel.: (650) 261-5075 / (650) 261-5076006006006 Email: adr@sanmateocourt.orgCivil & Probate ADR ProgramFinancial Aid Request InstructionsIn some instances, a party in a lawsuit may have difficulty paying a mediator/ADR neutral222s hourly fees. If this is the case, a party can apply for a full or partial waiver of these fees by completing the attached financial aid application and submitting it to the court222s ADR offices within five business days of their referralto ADR and/or their case management hearing.If financial assistance is granted to one party in a case, it does NOT affect the portion of the ADR neutral222sfees paid by the other parties in the case. Neutrals waive fees for up to 6 hours of work.To apply for financial assistance for ADR services, you need to:1) Complete the attached Financial Aid Application.This information is confidential and will not be placed in the court case files. If you do not qualify for a complete waiver of fees, you still may qualify for a partial waiver, and will be asked to contribute fees on a reduced basis.2) If an application is granted, all the parties in a case must then select the names of 4-5mutually agreed upon neutrals from the Financial Aid Panelist List. Parties must submit those names within the time specified by ADR staff.Note: If the list of mutually agreed upon neutrals is not received within the time specified, the financial assistance may be withdrawn.The list of potential neutrals submitted to the ADR offices can include the name of only one retired judge. Resumes of panel neutrals can be found on the court222s website atwww.sanmateocourt.org/adr.3) Assignment of a neutral and scheduling of ADR session.ADR staff will notify counsel/parties which MAP panelist has been assigned to handle the case. After the neutral is assigned, parties schedule the ADR session directly with the neutral222s office.4) Parties execute and file a Stipulation and Order to ADR with the Clerk of the Court,identifying the name of the neutral and the date of the ADR session.If parties fail to file the required Stipulation & Order to ADR within the specified time, the assigned neutral may be released from his/her obligation to handle the case. These services are offered as a courtesy and, if not properly utilized, can be withdrawn at the discretion of ADR staff.The granting or denying of financial assistance by ADR staff has no bearing on future court proceedings. This application is used solely for purposes of determining a party222s ability to pay for mediation/ADR services. Please contact ADR Program staff directly if you have any further questions at (650) 261-5075 or(650) 261-5076. American LegalNet, Inc. www.FormsWorkFlow.com 2Form ADR-9 [Rev. June 2018]Multi-Option ADR Project Superior Court of San Mateo County 400 County Center, Redwood City, CA 94063-1655 Tel: (650) 261-5075 or 261-5076 / Email: adr@sanmateocourt.org Application for Financial Aid for ADR Services Name: Case No: Address: Number Street City State Zip Case Name: Phone No.: () Date of Birth: / / All information in this application will be kept confidential and reviewed only by court ADR staff. Please answer the following questions: Yes No N/A 1. Are you currently working? Name of your employer: 2. Are you self-employed? 3. If unemployed, do you expect to be working soon? 4. Do you get any money from any other source (welfare, pension, unemployment, disability, alimony, spousal support, etc.)? 5. Are you married? 6. Does your spouse have a job? 7. Does your spouse get any money from any other source? 8. Do you own, or are you buying your home? 9. Do you have a checking or a savings account? Does your spouse have a checking or savings acco10.unt? Do you and/or your11.spouse own: 267 a car? If so, please list value on next page 267 stocks or bonds? If so, please list value on next page 267 trailer, boat or other vehicles? If so, please list value on next page 12. Household income: (List the information for the people that live in your home, other than yourself) Name Age Relationship Monthly take-home income TOTAL: (1) $ (2) $ $ (3) $ (4) $ Do not fill out this form if you filed a Request to Waive Court Fees. If granted, attach a copy of the Order on Court Fee Waiver to this application and then sign on last page. American LegalNet, Inc. www.FormsWorkFlow.com 3 13. If you are unemployed, how have you supported yourself while unemployed? Your Monthly Income Your Monthly Expenses Your take-home pay per month $ Rent payment per month $ Your spouse222s take-home pay per month $ Mortgage and insurance payment per month $ Other income per month (#4 from previous page) $ Food and groceries $ $ Utilities (gas, electric, phone, garbage) $ Total Monthly Income: $ Insurance (medical, dental, life, auto) $ Medical/Dental Payments (not covered by insurance) $ Your Assets Child care and school expenses $ Money in your checking and savings account(s) $ Spousal support you pay $ Money in your spouse222s checking and savings account(s) $ Transportation (car payments, gas, and public transportation) $ Equity in real estate and business interests $ IRS/Franchise Tax Board payments $ Money owed to you or your spouse $ Other expenses: (specify) $ Amount of tax refund you will receive $ $ Cash value of your insurance, stocks or investment accounts $ $ Cash value of your spouse222s insurance, stocks or investment accounts $ $ Cash value of autos, trailers, and/or boats $ $ Other: $ $ Total Assets: $ Total Monthly Expenses: $ I declare that all the information provided above is true and accurate. Date: / / Signature of Applicant Instructions: 267 Submit this application to the MAP offices within 5 business days of your case management conference hearing. You can fax it to (650) 261-5146. 267 If you are represented by an attorney, attach a copy of the attorney-client fee/retainer agreement. 267 Do not serve a copy of this application on opposing counsel. 001 Pro Bono 001 Modest means For office use only:001 Approved001 DeniedDate: / / Form ADR-9 [Rev. June 2018] Reviewer: American LegalNet, Inc. www.FormsWorkFlow.com