San Mateo — Solicitud de ayuda financiera para la ADR

Source: https://sanmateo.courts.ca.gov/system/files/local-forms/adr-9.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO MULTI OPTION ADR PROJECT HALL OF JUSTICE AND RECORDS 400 COUNTY CENTER REDWOOD CITY, CALIFORNIA 94063 Tel.: (650)261-5075 / (650)261-5076 Email: adr@sanmateocourt.org

Civil & Probate ADR Program

Financial Aid Request Instructions

In some instances, a party in a lawsuit may have difficulty paying a mediator/ADR neutral’s hourly fees. If this is the case, a party can apply for a full or partial waiver of these fees by completing the attached financial aid application and submitting it to the court’s ADR offices within five business days of their referral to ADR and/or their case management hearing.

If financial assistance is granted to one party in a case, it does NOT affect the portion of the ADR neutral’s fees paid by the other parties in the case. Neutrals waive fees for up to 6 hours of work.

To apply for financial assistance for ADR services, you need to:

1) Complete the attached Financial Aid Application.
This information is confidential and will not be placed in the court case files. Please email the
completed application to adr@sanmateocourt.org.

2) If an application is granted, all the parties in a case must then select the names of 4-5
mutually agreed upon neutrals from the Financial Aid Panelist List. Parties must submit
those names within the time specified by ADR staff.

Note: If the list of mutually agreed upon neutrals is not received within the time specified, the
financial assistance may be withdrawn.

The list of potential neutrals submitted to the ADR offices can include the name of only one retired
judge. Resumes of panel neutrals can be found on the court’s website at
www.sanmateo.courts.ca.gov/adr .

3) Assignment of a neutral and scheduling of ADR session.
ADR staff will notify counsel/parties which MAP panelist has been assigned to handle the case.
After the neutral is assigned, parties schedule the ADR session directly with the neutral’s office.

4) Parties execute and file a Stipulation and Order to ADR with the Clerk of the Court,
identifying the name of the neutral and the date of the ADR session.
If parties fail to file the required Stipulation & Order to ADR within the specified time, the assigned
neutral may be released from his/her obligation to handle the case. These services are offered as a
courtesy and, if not properly utilized, can be withdrawn at the discretion of ADR staff.

The granting or denying of financial assistance by ADR staff has no bearing on future court proceedings. This application is used solely for purposes of determining a party’s ability to pay for mediation/ADR services. Please contact ADR Program staff directly if you have any further questions at (650) 261-5075 or (650) 261-5076.

Multi-Option ADR Project Superior Court of San Mateo County 400 County Center, Redwood City, CA 94063-1655 Tel: (650) 261-5075 or 261-5076 / Email: adr@sanmateocourt.org

Application for Financial Aid for ADR Services

Do not fill out this form if you filed a Request to Waive Court Fees.

If granted, attach a copy of the Order on Court Fee Waiver to this application and then sign on last page.

Name: Case No:

---

Address: ____________________________________________ Case Name: Number Street ________________________________

---

City State Zip _________________________________

Phone No.: ()______________________ Date of Birth: ____ / __ _ / ______

All information in this application will be kept confidential and reviewed only by court ADR staff. Yes No N/A

Please answer the following questions:

1. Are you currently working?

Name of your employer: _______________________________________

2. Are you self-employed?
3. If unemployed, do you expect to be working soon?
4. Do you get any money from any other source
(welfare, pension, unemployment, disability, alimony, spousal support, etc.)?
5. Are you married?
6. Does your spouse have a job?
7. Does your spouse get any money from any other source?
8. Do you own, or are you buying your home?
9. Do you have a checking or a savings account?
10. Does your spouse have a checking or savings account?
11. Do you and/or your spouse own:
• a car? If so, please list value on next page
• stocks or bonds? If so, please list value on next page
• trailer, boat or other vehicles? If so, please list value on next page

12. Household income: (List the information for the people that live in your home, other than yourself)

Name Age Relationship Monthly take-home income TOTAL:

(1) ________________ _____ _______________ $__________ (2) ________________ _____ _______________ $__________ $_________ (3) ________________ _____ _______________ $__________ (4) ________________ _____ _______________ $__________ Form ADR-9 [Rev. June 2018] 2

13. If you are unemployed, how have you supported yourself while unemployed?

---

Your Monthly Income Your Monthly Expenses

Your take-home pay per month $ Rent payment per month $

Your spouse’s take-home pay per month $ Mortgage and insurance payment per month $

Other income per month $ Food and groceries $ (#4 from previous page) $ Utilities (gas, electric, phone, garbage) $

$
Total Monthly Income: $ Insurance (medical, dental, life, auto)
$
Medical/Dental Payments (not covered by
insurance)

Your Assets Child care and school expenses $

Money in your checking and savings $ Spousal support you pay $ account(s) Money in your spouse’s checking and $ Transportation (car payments, gas, and $ savings account(s) public transportation) $ IRS/Franchise Tax Board payments $ Equity in real estate and business interests Money owed to you or your spouse $ Other expenses: (specify) $

Amount of tax refund you will receive $ $

Cash value of your insurance, stocks or $ $ investment accounts Cash value of your spouse’s insurance, $ $ stocks or investment accounts Cash value of autos, trailers, and/or boats $ $

Other: $ $

Total Assets: $ Total Monthly Expenses: $

I declare that all the information provided above is true and accurate.

Date: ____ / ___ / ______ _______________________________________ Signature of Applicant Instructions: • Submit this application to the MAP offices within 5 business days of your case management conference hearing. You can email the application to adr@sanmateocourt.org. • If you are represented by an attorney, attach a copy of the attorney-client fee/retainer agreement. • Do not serve a copy of this application on opposing counsel.

For office use only: □ Approved □ Pro Bono □ Denied □ Modest means

Date: ______ / ____ / ______ Reviewer: ____________________________

Form ADR-9 [Rev. June 2018] 3