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ADR-109

CASE NUMBER:

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

4. Subject matter of reference.

Section 638. Applicant requests that the reference include (check and complete one):

(1)

all issues in dispute.

(2)

the following issues (describe issues to be covered by reference below or in Attachment 4a):

Section 639. Applicant requests that the reference include the following issues (describe issues below or in

Attachment 4b):

5. Referee's compensation. (Check and complete one.)

The referee will not be privately compensated by the parties.

The referee will be privately compensated by the parties as follows:

(1)

The parties have agreed that the referee's fees shall be paid as follows (state agreement below or in

Attachment 5b):

(2)

The parties have not agreed on payment of the referee's fees and request the matter to be resolved by the

court under Code of Civil Procedure section 645.1.

6. Use of court facilities and personnel. (Check and complete one.)

Applicant does not request the use of court facilities or court personnel.

Applicant requests the use of court facilities or court personnel. (Describe the requested use below or in attachment

6b. If the reference is to be conducted by a privately compensated referee appointed under Code Civ. Proc., § 638,

also state why the use of court facilities or court personnel will further the interest of justice. Court facilities and

personnel may be used in proceedings before a privately compensated section 638 referee only upon a finding of the

presiding judge that the use would further the interest of justice.)

7. Hearing location information. The following person may be contacted to arrange attendance at any proceeding that is open to

the public and that is conducted in a private facility (complete all of the following):

a. Name:

b. Address:

c. Telephone:

Date:

(TYPE OR PRINT NAME)