Amador — Mediator's Claim Form

Source: https://amador.courts.ca.gov/system/files/forms-and-filings/mediator-claimform.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF AMADOR 500 ARGONAUT LANE, JACKSON, CA 95642 Name, Address and Telephone No. of Mediator/Evaluator CLERK’S USE ONLY

Telephone No: Case No.

Case Title: Invoice Date:

FAMILY LAW AND CIVIL MEDIATION CLAIM FORM AND ORDER

CLAIM AND REQUEST FOR APPROVAL OF: FAMILY LAW MEDIATION FEES CIVIL MEDIATON FEES EVALUATOR’S FEES

To the Judge of the Superior Court: Pursuant to No. 5 of the General Mediation Procedures adopted by the Amador County Superior Court, there is herewith presented a claim for fees in the above-entitled cause:

FAMILY LAW MEDIATION GL #939101 TIME/HOURS _____________ Agreement Petitioner did not show for Refer for Evaluation Other: __________ Mediation ____________________ Partial Agreement Respondent did not show Recommended for Minor’s Counsel (FC 3184) No Agreement for Mediation

$210.00 $105.00 $50.00 Set fee for mediation Quarterly Meeting One or both parties did not show

Date:____________________________ Mediator: ____________________________________ (For Statistical Purposes Only) Did the issues in mediation involve Domestic Violence Substance Abuse Not Applicable Child Abuse

CIVIL MEDIATION ($150.00) FAMILY LAW EVALUATION ($600.00 per client)

Mediation Date: ____________________ TOTAL CLAIM: $________________

I declare under penalty of perjury that the itemized statement and claim for services attached hereto is true and correct and

accurately reflects the time spent by me in this action.

Date:____________________ Mediator/Evaluator: __________________________________________ ___________________________________________________________ Date:____________________ _ Dawn Harmon, Court Executive Officer

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ORDER

Amount Approved: $_________________

Date: ____________________ ____________________________________________________________ Judge of the Superior Court MEDIATION AND EVALUATOR’S CLAIM FORM AND ORDER-(Rev. 10/05/2012)-FIN-022

ITEMIZED STATEMENT

CASE NO.:

SERVICE DATE TYPE OF SERVICE # OF HOURS RATE COST

TOTAL # OF HOURS ________ X $_________/HOUR = $

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Date Signature

MEDIATION AND EVALUATOR’S CLAIM FORM AND ORDER-(Rev. 10/05/2012)-FIN-022