ARBITRATOR’S FEE STATEMENT
Approved for Optional Use California Rules of Court, rule 3.819
L-0190 (Rev. 'HF201)
Arbitrator Name and Address:
Telephone No.: Fax No. (Optional):
E-Mail Address (Optional):
PLAINTIFF/PETITIONER:
DEFENDANT/RESPONDENT:
ARBITRATOR’S FEE STATEMENT
CASE NUMBER:
Pursuant to California Rul es of Court, rule 3.819 a nd Local Rules - Superior Court of California, County of Orange,
rule 360, the following fee(s) are requested for conducting arbitration proceedings in the above-named case. (Attach a
declaration to support payment of fees if the case settled at the hearing, no hearing was conducted or extraordinary
fees are requested.)
Date session concluded:
Date Award or Settlement filed with the Court:
Name of Arbitrator: Fee(s) Requested
Name of Payee:
Fee for entire session: $ 150.00
Address of Payee:
Extraordin ary fees:
TOTAL:
Last four digits of your Social Security # or your full Taxpayer Identification #:
A current signed IRS Form W-9 or Payee Data Records is: attached has been submitted to the Court
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 Clerk’s Use Only)
'$9,'+<$0$6$.,, Clerk of the Court
Amount approved: $
By:
Authorization __________________________________________ Deputy Clerk
(For Accounting Services Use Only)
Review and Authorization Accounting Services Approval
Date:
By: Date: Authorized By:
Account Coding
G/L Acct.
Cost/Fund Center
WBS Element Functional Area PCT Fund Tax Code Amount
939102 306311 1220 110001
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE
Central - 700 Civic Center Dr. West, Santa Ana, CA 92701-4045
Harbor - Newport Beach Facility - 4601 Jamboree Rd, Newport Beach, CA 92660-2895
North - 1275 N. Berkeley Ave., P. O. Box 5000, Fullerton, CA 92838-0500
West - 8141 13th Street, Westminster, CA 92683-4593
