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NAME AND ADDRESS OF ATTORNEY: FOR COURT USE ONLY

TELEPHONE NUMBER: SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 650 Wake Avenue, El Centro, CA 92243 939 West Main Street, El Centro, CA 92243 PLAINTIFF/PETITIONER:

DEFENDANT/RESPONDENT:

ARBITRATOR’S FEE STATEMENT CASE NUMBER:

Pursuant to California Rules of Court, rule 3.819 and Local Rules – Superior Court of California, County of Imperial, rule 3.5.6, the following fee(s) are requested for conducting arbitration proceedings in the above named case.

Date session concluded: _________________ Date Award/Settlement filed with Court:_______________

Name of Arbitrator: _______________________ Length of Session: _______________________

Name of Payee: __________________________ Fee(s) Requested:________________________

Address of Payee: ______________________

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Social Security number or Taxpayer Identification number: ______________________________

I declare under penalty of perjury, under the laws of the State of California that the foregoing is true and correct.

Date: ___________________ Signature of Arbitrator: ______________________________

FOR COURT USE ONLY

Amount authorized _____________

Date: ____________________ ____________________________________ (ARBITRATION ADMINISTRATOR)

Form Adopted for Mandatory Use www.imperial.courts.ca.gov CV-01 (Adopted 01/01/12, Revised 01/01/13, 01/01/24) ARBITRATOR’S FEE STATEMENT