REQUEST AND STIPULATION FOR REFERRAL State of Connecticut TO A PRIVATE ALTERNATIVE DISPUTE SUPERIOR COURT RESOLUTION (ADR) PROVIDER www.jud.ct.gov JD-CL-54 Rev. 1-08 P.B. § 23-67 C.G.S. §§ 52-195b, 235c COURT USE ONLY C.G.S. § 52-235c - ADRSTIP C.G.S. § 52-195b - ADRCSNT INSTRUCTIONS TO APPLICANTS TO CLERK 1. All counsel or pro se parties must sign fully completed form. 2. All parties should make and retain a copy for their records. 3. Submit both parts of this form to the Superior Court Clerk's Office in which your case is pending. 1. Bring this completed form and the file to the civil/family presiding judge. 2. Notify counsel and pro se parties of record of the court's decision. NAME OF CASE DOCKET NO. ADDRESS OF COURT (No., Street, Town, State and Zip Code) Judicial District Housing Session TYPE OF CASE (Check one) CIVIL FAMILY TRIAL LIST CLAIM FILED HOUSING NO YES CLAIM DATE: TRIAL DATE: RETURN DATE IF YES: REQUEST AND STIPULATION All parties hereby request and stipulate that the above-entitled case shall be submitted to a private Alternative Dispute Resolution provider as follows: C.G.S. § 52-235c - General ADR C.G.S. § 52-195b - Private Passenger M.V. ADR 1. AUTHORITY FOR REQUEST: (CHECK ONLY ONE) 2. TYPE OF ADR: Non-Binding Mediation Binding Arbitration Other 3. ADR PROVIDER: (Specify Name of ADR Provider Selected By Parties) 4. SCOPE OF ADR: All issues Liability only Damages only Provider No. (See Clerk for List) Discovery disputes 5. REQUESTED REFERRAL PERIOD: (Not to Exceed Ninety Days) 6. SPECIAL CONDITIONS IF ANY: PLAINTIFF COUNSEL/PRO SE DEFENDANT COUNSEL/PRO SE (Signature) (Date) (Signature) (Date) (Signature) (Date) (Signature) (Date) (Signature) (Date) (Signature) (Date) ORDER The foregoing request and stipulation having been reviewed by this court it is hereby ORDERED that: the above-entitled case is referred to Alternative Dispute Resolution, and all court proceedings are stayed through or until the ADR process is completed, whichever occurs first. (Specify date - Not to exceed ninety days) the above-entitled case is not referred to Alternative Dispute Resolution. the above-entitled case does not meet the requirements of C.G.S. § 52-195b. The parties are ordered to file an ADR Result Report with the clerk's office no later than five days after the expiration of the above stay. Special Conditions of Order: BY THE COURT: (Judge/Clerk) DISTRIBUTION: White - Clerk's Office (Date) Yellow - Caseflow American LegalNet, Inc. www.FormsWorkFlow.com