Employment Arbitration Rules Demand For Arbitration (FOR USE ONLY IN CALIFORNIA) Pursuant to Section 1284.3 of the California Code of Civil Procedure, consumers with a gross monthly income of less than 300% of the federal poverty guidelines are entitled to a waiver of arbitration fees and costs, exclusive of arbitrator fees. This law applies to all consumer agreements subject to the California Arbitration Act, and to all consumer arbitrations conducted in California. Only those disputes arising out of employer promulgated plans are included in the consumer definition. If you believe that you meet these requirements, you must submit to the AAA a declaration under oath regarding your monthly income and the number of persons in your household. Please contact the AAA’s Western Case Management Center at 1-877-528-0879, if you have any questions regarding the waiver of administrative fees. MEDIATION: If you would like the AAA to contact the other parties and attempt to arrange a mediation, please check this box. There is no additional administrative fee for this service. Name of Respondent Name of Representative (if known) Address: Name of Firm (if applicable) Representative’s Address City State City Fax No. Phone No. Zip Code Phone No. Email Address: State Zip Code Fax No. Email Address: The named claimant, a party to an arbitration agreement dated _________________________, which provides for arbitration under the Employment Arbitration Rules and Mediation Procedures of the American Arbitration Association, hereby demands arbitration. THE NATURE OF THE DISPUTE Dollar Amount of Claim $ Other Relief Sought: Arbitration Costs Attorneys Fees Interest Punitive/ Exemplary Other ____________ ___ ___ AMOUNT OF FILING FEE ENCLOSED WITH THIS DEMAND (please refer to the fee schedule in the Rules for the appropriate Fee) $ _________ Employer-Promulgated Plan Individually Negotiated Employment Agreement Flexible Fee Schedule Standard Fee Schedule If Individually Negotiated Employment Agreement, select Fee Schedule: PLEASE DESCRIBE APPROPRIATE QUALIFICATIONS FOR ARBITRATOR(S) TO BE APPOINTED TO HEAR THIS DISPUTE: Hearing locale________________________ (check one) Estimated time needed for hearings overall: __________hours or ___________days Requested by Claimant Claimant Respondent Locale provision included in the contract Employee Employee Employer Employer Does this dispute arise out of an employment relationship? Yes No What was/is the employee’s annual wage range? Note: This question is required by California law. Less than $100,000 $100,000 - $250,000 Over $250,000 You are hereby notified that copies of our arbitration agreement and this demand are being filed with the American Arbitration Association at its_______________________ office, with a request that it commence administration of the arbitration. Under the rules, you may file an answering statement within 15 days after notice from the AAA. Signature (may be signed by a representative) Date: Name of Representative Name of Claimant Name of Firm (if applicable) Address (to be used in connection with this case) Representative’s Address City Zip Code City Fax No. Phone No. Phone No. Email Address: State State Zip Code Fax No. Email Address: To begin proceedings, please send two copies of this Demand and the Arbitration Agreement, along with the filing fee as provided for in the Rules, to the AAA. Send the original Demand to the Respondent. Please visit our website at www.adr.org if you would like to file this case online. AAA Customer Service can be reached at 800-778-7879 American LegalNet, Inc. www.FormsWorkFlow.com