(818)551-2822 Sacramento Regional Office 1031 18th Street Sacramento, CA 9581-4174 (916)322-3198 San Francisco Regional Office 1330 Broadway, Suite 1532 Oakland, CA 94612-2514 (510)622-1016 PERB-1510 (0/1) Page 1 of 2 REQUEST FOR IMPASSE DETERMINATION/ APPOINTMENT OF MEDIATOR DO NOT WRITE IN THIS SPACE: Case No.:Date Filed: INSTRUCTIONS : A request for impasse determination must be filed with the appropriate regional office (see PERB Regulation 32075). A request which is not jointly filed must be served on the other party as required by Regulation 32792(b). Proof of service must accompany the request. Attach additional sheets if more space is required. 1.The employer of the employees in the established unit is an employer within the meaning of the :Educational Employment Relations Act (EERA) (Gov. Code, 247247 3540-3549.3). Higher Education Employer-Employee Relations Act (HEERA) (Gov. Code, 247247 3560-3599). Ralph C. Dills Act (Dills Act) (Gov. Code, 247247 3512-3524). 1.EMPLOYER Name:Address: Agent to be contacted: Name: Title: Agency/Firm: Address: : E-mail Address: 2.EXCLUSIVE REPRESENTATIVE Name:Address: Agent to be contacted: Name: Title: Union/Firm: Address: hone: E-mail Address: 4. DESCRIPTION OF ESTABLISHED UNIT Shall Include: Shall Exclude: 5.APPROXIMATE NUMBER OF EMPLOYEES IN THE UNIT: 6.DATE EXCLUSIVE REPRESENTATIVE WASRECOGNIZED OR CERTIFIED: 7. TYPE OF DISPUTE Initial Contract Successor Contract Reopener(s) in Existing Contract Effects of Layoff Other (describe) 8. PUBLIC NOTICE REQUIREMENTS Date exclusive representative222s initial proposals presented to the public:Date employer222s initial proposals presented to the public: American LegalNet, Inc. www.FormsWorkFlow.com PERB-1510 (0/1) Page 2 of 2 9. HISTORY OF NEGOTIATIONS/MEET AND CONFER Date of first negotiations session:Approximate total number of hours spent in negotiations to date: Total number of negotiating sessions to date: 10. STATUS OF NEGOTIATIONS/MEET AND CONFER Date impasse was declared by a party/partiesTotal number of unresolved issues which remain in dispute: pursuant to PERB Regulation 32792(a): Number of issues on which the partiesIssues which remain in dispute: have reached tentative agreement: Issues on which tentative agreement has been reached: 11. STATEMENT OF FACTS Provide a clear and concise description of the negotiations which have occurred, including the extent to which the parties have made counter-proposals and have discussed the issues which remain in dispute. Identify the facts which indicate that future meetings without the assistanceof a mediator would be futile. DECLARATION I declare under penalty of perjury that the statements herein are true to the best of my knowledge and belief. NAME OF REQUESTING PARTY: SIGNATURE OF AUTHORIZED REPRESENTATIVE: Title: Date: NAME OF REQUESTING PARTY: SIGNATURE OF AUTHORIZED REPRESENTATIVE: Title: Date: (Attach a completed Proof of Service form.) American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE I declare that I am a resident of or employed in the County of , State of . I am over the age of 18 years. The name and address of my residence or business is . On , I served the (Date) (Description of document(s)) (Description of document(s) continued) on the parties listed below (include name, address and, where applicable, fax number) by (check the applicable method or methods): placing a true copy thereof enclosed in a sealed envelope for collection and delivery by the United States Postal Service or private delivery service following ordinary business practices with postage or other costs prepaid; personal delivery; facsimile transmission in accordance with the requirements of PERB Regulations 32090 and 32135(d). (Include here the name, address and, where applicable, fax number of the Respondent and any other parties served.) I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed on , at . (Date) (City) (State) (Type or print name) (Signature) American LegalNet, Inc. www.FormsWorkFlow.com