Mediation Statement Template
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1ATTORNEY OR PARTY WITHOUT ATTORNEY
FOR COURT USE ONLY
(NAME, STATE BAR # AND ADDRESS):
TELEPHONE NO.
FAX NO. (
)
Optional
EMAIL ADDRESS (
)
Optional
ATTORNEY FOR (NAME):
Superior Court of California, County of Sacramento
720 Ninth Street, Room 101
Sacramento, CA 95814-1380
(916) 874-5522—Website
PLAINTIFF/PETITIONER:
DEFENDANT/RESPONDENT:
:
CASE NUMBER
MEDIATION STATEMENT
ASSIGNED DEPT:
A CASE MANAGEMENT CONFERENCE is scheduled as follows:
Date:
Time:
Dept.:
Address of court (if different from the address above):
INSTRUCTIONS: All applicable boxes must be checked, and the specified information must be provided.
All parties have considered Mediation as a means to resolving this case and have agreed:
Mediation is appropriate for this case. Parties have submitted a Stipulation and Order for Mediation form or
will submit a Stipulation within 14 days following the Case Management Conference.
Mediation is not appropriate for this case for the following reasons:
I am completely familiar with this case and will be fully prepared to discuss the status of discovery and Alternative Dispute
Resolution (ADR), as well as other issues raised by this statement, and will possess the authority to enter into stipulation on these
issues at the time of the Case Management Conference, including the written authority of the party where required.
Date: ______________________
_____________________________________________
___________________________________________
(Type or Print Name)
(Signature of Party or Attorney)
_____________________________________________
___________________________________________
(Type or Print Name)
(Signature of Party or Attorney)
Mediation Statement
CV\E–MED–172 (Rev 02.13.09)
Local Form Adopted for Mandatory Use
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