ADR-100 - Statement of Agreement or Nonagreement

Summary

Statement of Agreement or Nonagreement

Text

Form ID: ADR-100
Title: Statement of Agreement or Nonagreement
Effective Date: 2012-07-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/ADR-100
Primary Download URL: https://www.courts.ca.gov/documents/adr100.pdf
Form Detail Page:
Statement of Agreement or Nonagreement
(ADR-100)
The mediator in a civil case that was sent to mediation by the court tells the court whether the mediation was held and whether the parties reached an agreement about the case in the mediation. Also tells the court that the mediator had this form delivered to (served on) the parties.
Get form ADR-100
Effective: July 1, 2012
PDF Text:
Form Adopted for Mandatory Use 
Judicial Council of California 
ADR-100 [Rev. July 1, 2012]
STATEMENT OF AGREEMENT OR NONAGREEMENT Code of Civil Procedure, § 1775.9 
Cal. Rules of Court, rule 3.895 
www.courts.ca.gov
ADR-100
MEDIATOR (Name and Address):
TELEPHONE NO.: FAX NO.:
                EMAIL ADDRESS:
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NAME:
FOR COURT USE ONLY
CASE NUMBER:STATEMENT OF AGREEMENT OR NONAGREEMENT
First Supplemental
The mediator must complete, serve, and file this form
• within 10 days after conclusion of the mediation, or by an another date set by the court, in all cases assigned to 
mediation under the Civil Action Mediation Program. (Code Civ. Proc., § 1775 et seq.) 
• as required by the court in other mediation programs. 
In completing this form, the mediator must not
• provide any information beyond what is specifically requested, or 
• disclose any settlement terms, confidential communications, mediation conduct, or mediator conclusions or  
impressions. (Evid. Code, § 1115 et seq.)
1. I was appointed, assigned, or retained as the mediator in this case on (date):
2. The mediation (check one) 
a.
was not scheduled.
b. was scheduled but not held.
c. was held as follows:
(1) Session dates (specify all): 
(2) Number of sessions:
(3) Total length of sessions (hours):
3. The mediation ended on (date):
a. in a full agreement. 
b. in a partial agreement.
c. in nonagreement.
4. The mediation has not yet ended. I submit this form to comply with the court’s requirement to do so by a specified date. 
(Complete the items below. In Civil Action Mediation Programs and where otherwise required by the court, file a 
supplemental  Statement of Agreement or Nonagreement within 10 days after the mediation ends or by such other date as 
the court may set.) 
a. The mediator anticipates that the mediation will be completed by (date): 
NOTICE TO PARTIES: This form does not extend any mediation completion deadline that the court has set. You must request 
any necessary extension from the court.
b. The next mediation session is scheduled for (date): 
Date:
(TYPE OR PRINT NAME)
 (SIGNATURE OF MEDIATOR)
Page 1 of 2

ADR-100 [Rev. July 1, 2012] STATEMENT OF AGREEMENT OR NONAGREEMENT Page 2 of 2
PROOF OF SERVICE OF STATEMENT OF AGREEMENT OR NONAGREEMENT
1. At the time of service, I was over 18 years of age and not a party to this action.
2. My residence or business address is:
3. The fax number or electronic service address from which I served the document is (complete if service was by fax or  
electronic service):
4. I served the Statement of Agreement or Nonagreement (form ADR-100) on the person or persons below, as follows: 
a. Name of person served
b. Manner of service  
(specify personal, 
mail, fax, or electronic)
c. Physical or mailing address,     
fax number, or electronic service  
address where person was served
d. Date        
of service
e. Time     
of service
5. The form ADR-100 was served by the following means (check and complete all that apply):
Where personal service is indicated in item 4.b., I personally delivered the form ADR-100 to the persons for whom  
personal service is indicated, at the addresses listed in item 4.c. (1) For a party represented by an attorney, delivery was  
made to the attorney or at the attorney's office by leaving the document in an envelope or package clearly labeled to  
identify the attorney being served with a receptionist or an individual in charge of the office, or in a visible location in the  
office between the hours of 9 a.m. and 5 p.m. (2) For a party, delivery was made to the party or by leaving the document  
at the party's residence with some person not younger than 18 years of age between the hours of 8 a.m. and 6 p.m.
a.
b.
Where service by mail is indicated in item 4.b., I enclosed the form ADR-100 in a sealed envelope or package 
addressed to the persons at the addresses in item 4.c. and (specify one):
(1) deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid.
(2) placed the envelope for collection and mailing, following our ordinary business practices. I am readily familiar              
with this business's practice for collecting and processing correspondence for mailing. On the same day that               
correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the             
United States Postal Service, in a sealed envelope with postage fully prepaid.
I am a resident of or employed in the county where the mailing occurred. The envelope or package was placed in the mail 
at (city and state):
c.
Where fax transmission is indicated in item 4.b., based on an agreement of the parties to accept service by fax 
transmission, I faxed the form ADR-100 to the persons at the fax numbers listed in item 4.c. No error was reported by the 
fax machine that I used. A copy of the record of the fax transmission, which I printed, is attached.
d.
Where electronic service is indicated in item 4.b., I caused the form ADR-100 to be served on the persons at the 
electronic service addresses listed in item 4.c., in accordance with a court order or an agreement of the parties allowing 
electronic service. 
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME)
 (SIGNATURE OF DECLARANT)

Retrieval chunks

• #1

  Form ID: ADR-100 Title: Statement of Agreement or Nonagreement Effective Date: 2012-07-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/ADR-100 Primary Download URL: https://www.courts.ca.gov/documents/adr100.pdf Form Detail Page: Statement of Agreement or Nonagreement (ADR-100) The m…

• #2

  supplemental Statement of Agreement or Nonagreement within 10 days after the mediation ends or by such other date as the court may set.) a. The mediator anticipates that the mediation will be completed by (date): NOTICE TO PARTIES: This form does not extend any mediation completion deadline that the court has set.…

• #3

  with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service, in a sealed envelope with postage fully prepaid. I am a resident…