San Francisco — Probate Pro Bono Mediation Program Application

Source: https://sf.courts.ca.gov/system/files/general/applicationpanel_2024_04_08-5.pdf

Superior Court of California County of San Francisco

Application For Individual Listing

SAN FRANCISCO SUPERIOR COURT

PROBATE COURT PRO BONO MEDIATION PANEL

I am applying for appointment to the Probate:

□ Trusts & Estates Panel

□ Conservatorship & Guardianship Panel

1. Contact Information Applicant's Name: ________________________________________________________ Current Occupation: ________________________________________________________ Firm Name: ________________________________________________________ Address: ________________________________________________________ ________________________________________________________

City/State/Zip: ________________________________________________________ Telephone: ()_________________ Fax: ()_________________ Email: ________________________________________________________

2. Licensing. Please provide the following:

(a) CA State Bar No. _____________ Date Admitted: _________ □ Active □ Inactive Bar Membership: Other States ___________________________________________ Certified Specialties: __________________________________________

(b) Are you licensed in a profession or occupation other than law? □ YES □ NO Occupation _____________________ License#________________________________ State________ Licensing Agency ___________________________________________

3. Areas of Expertise (a) Check areas of expertise or background, in law or mediation. Law Med Law Med Law Med □ □ Conservatorships □ □ Partnership/Corporate □ □ Family Law-Other □ □ Elder Abuse □ □ Real Estate/Property □ □ Other Quality of Life □ □ Landlord/ Tenant □ □ Tax Issues (e.g., neighbor □ □ Probate □ □ Family Law- disputes) □ □ Trusts Custody/Visitation □ □ Other (please indicate): _______________________________

(b) Indicate any other special attributes, skills, interests or aspects of your practice:

(c) I am fluent and able to conduct mediations in the following language(s): □ Spanish □ Cantonese □ Mandarin □ Other: _____________________

4. Mediation Rates in Excess of Pro Bono Time (a) The Probate Pro Bono Mediation Panels provide for up to 2 hours of preparation time and up to 4 mediation time. If the parties voluntarily agree to continue the mediation with the mediator, they may agree to pay the mediator an hourly rate.

   My current rate for mediation is: $ ___________ per: ___________

   If there is a sliding scale fee or other arrangement available for lower income parties, please describe:

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(b) Will you accept cases with self-represented litigants? □ YES □ NO

5. Mediation Training and Experience. Please affirm any or all of the below information and be sure to provide evidence satisfying the applicable option(s).

(a) □ I have completed a comprehensive mediation training, which includes: □ At least one basic mediator-training course, covering conflict/communication theory, stages of mediation process, mediation skills/techniques, ethics, etc.; □ Experiential training (e.g., demonstrations, role playing); and □ The laws governing mediation, including mediation confidentiality.

MEDIATION TRAINING. Attach additional pages if necessary. Organization/ Course Title/ No. of Month/Year Provider Brief Description of Training Hours Attended

(b) OTHER RELEVANT TRAINING (Including Temporary Judge Training). Organization Course Title Hours Month/Year

(c) I have been a trained mediator for: □ 1-5years □ 6-10 years □ 10+years

(d) ADR PANELS. Please list the court, county and/or other private, community, or volunteer agencies in which you have served. Attach additional pages if necessary. ADR Panel Title/ From To Type & Location (Month/Year) (Month/Year)

(e) AFFILIATION WITH OTHER DISPUTE RESOLUTION ORGANIZATIONS. Name of Provider Organization Nature of Affiliation Number of Years

(f) MEDIATION EXPERIENCE. I have served as the mediator or co-mediator in at least five cases within the past three years, as follows (please do not list case names): Panel/Organization Case Type/ Number Date Mediated For Subject Matter of Hours (Mo/Year) 1. 2. 3. 4. 5.

Approximately how many mediations in total have you conducted as a mediator?

6. Disciplinary Actions and Criminal History

(a) I □ have □ have not pleaded guilty or no contest to, or been convicted of, a felony or misdemeanor. If you have, please explain fully:

(b) I □ have □ have not been suspended or subject to disciplinary action as a result of an investigation from a professional organization, public entity or mediation program. If you have, please explain fully:

(c) I □ am □ am not aware of any pending disciplinary action against me by any professional organization, public entity or mediation program. If you are, please explain fully:

Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case is considered individually. Failure to list criminal convictions or professional disciplinary actions taken against you, however, will result in automatic removal from the program.

7. Additional Information. Please provide a brief description of any additional information that you would like considered:

8. References. List three or more persons who are familiar with your work as a mediator and/or have appeared before you in mediation. (Please be mindful of confidentiality and to seek prior permission to use these names.)

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: EMAIL:

RELATIONSHIP TO CASE (ATTORNEY, PARTY, CO-MEDIATOR OR OTHER):

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: EMAIL:

RELATIONSHIP TO CASE (ATTORNEY, PARTY, CO-MEDIATOR OR OTHER):

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: FAX: EMAIL:

RELATIONSHIP TO CASE (ATTORNEY, PARTY, CO-MEDIATOR OR OTHER):

9. Certification. In completing this application, I represent that:

☐ I am willing and able to conduct mediations in San Francisco, if that is where the parties prefer to meet. ☐ I have read and will fully comply with the California Rules of Court, rule 3.850 et seq., regarding Rules of Conduct for Mediators in Court-Connected Mediation Programs for Civil Cases. ☐ I agree to complete all mediation program forms as directed by the Court. ☐ I agree to mediate at least two pro bono cases per year as assigned by the Court. ☐ I agree to report to the ADR Administrator any criminal case in which I pled guilty or no contest or in which I am convicted as well as any disciplinary action taken against me by any state, federal or professional licensing board and/or agency.

I declare, under penalty of perjury under the laws of the State of California, that the information provided in this application is true and correct to the best of my knowledge.

Date: Print name:

Signature:

Please return this form and additional written information as described in the instructions to:

Probate Director

San Francisco Superior Court 400 McAllister, Room 202 San Francisco, CA 94102-4514 FAX: (415) 551-3651 akim@sftc.org

PLEASE NOTE: INCLUSION ON THE PROBATE PRO BONO MEDIATION PANELS IS IN THE SOLE DISCRETION OF THE PROBATE BENCH OFFICERS IN CONSULTATION WITH THE PROBATE ADVISORY COMMITTEE AND IS NOT GUARANTEED.