This form is for members of the Civil Mediation Panel who provided a Court-Ordered Mediation pursuant to Local Rule, Title 3, Division 2. Please submit this form within ten (10) days of the mediation to the Coordinator of ADR Services:
4050 Main Street, Riverside, CA 92501; ADRDirector@riverside.courts.ca.gov
RI-ADR07
Have you filled out the Payee Data Record Form?*field type radio button
Have you filled out the Payee Data Record Form?YesNo
Has your address changed since last payment received by the court?*field type radio button
Has your address changed since last payment received by the court?YesNo
Email Address*field type single line
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Section A. Mediator's Information

Mediator's Name*field type single line
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Phone Number*field type single line
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This information must match the information on your vendor payee form
Address*field type single line
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Unitfield type single line
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City*field type single line
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State*field type single line
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Section B. Mediation Information

Case Name*field type single line
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Case Number*field type single line
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Mediation Details
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- Date of Mediation*field type date
- Length of Session*field type single line
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Add
*field type checkbox
I certify that I was the mediator in the above-entitled case that was mediated pursuant to Local Rule Title 3, Division 2.
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I certify that at the time the mediation was held, I was an active member of the Court's Civil Mediation Panel.
As confirmation of my service:
1. Date Case Ordered to Court-Ordered Mediation*field type date
Mail Statefield type single line
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2. Date Notice of Acceptance Filed*field type date
3. Date Statement of Agreement/Non-Agreement Filed*field type date
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I request payment of $225.00 for my service. (Payments from mediations before 10/1/2021 will be $150.00)

I declare under penalty of perjury the foregoing to be an accurate statement of services rendered in this case.
Date*field type date
Signature*field type signature
Last Name Hiddenfield type single line
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varMediatorNamefield type single line
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Mail Addressfield type single line
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Mail Unitfield type single line
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Mail Cityfield type single line
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Mail Zipfield type single line
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