Form Adopted by the Judicial Council of California ADR-101 [New March 1, 1994] ADR INFORMATION FORM NAME OF COURT: ADR Information Form This form should be filled out and returned, within 10 days of the resolution of the dispute, to: 1. Case name: No. 2. Type of civil case: PI/PD-Auto PI/PD-Other Contract Other (specify): 3. Date complaint filed Date case resolved 4. Date of ADR conference 5. Number of parties 6. Amount in controversy $0–$25,000 $25,000–$50,000 $50,000–$100,000 over $100,000 (specify): 7. Plaintiff's attorney Cross Complainant's Attorney NAME ADDRESS TELEPHONE NUMBER 8.

Defendant's Attorney Cross Defendant's Attorney NAME ADDRESS TELEPHONE NUMBER 9. Please indicate your relationship to the case: Plaintiff Plaintiff's attorney Defendant Defendant's attorney 3rd party defendant 3rd party defendant's attorney Other (specify): 10. Dispute resolution process: Mediation Arbitration Neutral case evaluation Other (specify): 11. How was case resolved? a. As a direct result of the ADR process. b. As an indirect result of the ADR process. c. Resolution was unrelated to ADR process. 12.

Check the closest dollar amount that you estimate you saved (attorneys fees, expert witness fees, and other costs) by using this dispute resolution process compared to resolving this case through litigation, whether by settlement or trial. $0 $250 $500 $750 $1,000 more than $1,000 (specify): $ 13. If the dispute resolution process caused a net increase in your costs in this case, check the closest dollar amount of the additional cost: $0 $250 $500 $750 $1,000 more than $1,000 (specify): $ 14.

Check the closest number of court days that you estimate the court saved (motions, hearings, conferences, trial, etc.) as a result of this case being referred to this dispute resolution process: 0 1 day more than 1 day (specify): 15. If the dispute resolution process caused a net increase in court time for this case, check the closest number of additional court days: 0 1 day more than 1 day (specify): 16. Would you be willing to consider using this dispute resolution process again? Yes No