ARBITRATION CERTIFICATION I,___________________________, counsel for ______________________ ____________do hereby certify pursuant to the Local Arbitration Rule 83.10 that to the best of my knowledge and belief the damages recoverable in the above captioned civil action exceed the sum of $150,000 exclusive of interest and costs. _____________ Relief other than monetary damages is sought. DISCLOSURE STATEMENT - FEDERAL RULES CIVIL PROCEDURE 7.1 Identify any parent corporation and any publicly held corporation that owns 10% or more or its stocks: ______________________________________________________________________________ Did the cause arise in Nassau or Suffolk County? _______________ If answered yes, please indicate which county. _________________ County of residence of plaintiff(s) (1)____________________ (2)____________________ (3)____________________ County of residence of defendant(s) (1)____________________ (2)____________________ (3)____________________ I am currently admitted in the Eastern District of New York and currently a member in good standing of the bar of this court. Yes_________ No_________ Are you currently the subject of any disciplinary action(s) in this or any other state or federal court? Yes_________(If yes, please explain) No_________ ______________________________________________________________________________ ______________________________________________________________________________ Please provide your E-MAIL Address and bar code below. Your bar code consists of the initials of your first and last name and the first four digits of your social security number or any other four digit number registered by the attorney with the Clerk of Court. (This information must be provided pursuant to local rule 11.1(b) of the civil rules). ATTORNEY BAR CODE:_____________ E-MAIL Address: _________________________________________ I consent to the use of electronic filing procedures adopted by the Court in Administrative Order No. 97-12, “In re Electronic Filing Procedures(EFP)”, and consent to the electronic service of all papers. Signature: _______________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com