Caption of Case:
Request to Substitute ADR Practitioner and Selection of ADR Practitioner by Stipulation
We agree to attend ADR conducted by
(Name, address, and telephone number of ADR Practitioner)
We have made payment arrangements with the ADR Practitioner, and we understand
that the court's fee schedules do not apply to this ADR. We request that the court substitute
this ADR Practitioner for the ADR Practitioner designated by the court.
(Signature of Plaintiff) (Signature of Defendant)
(Signature of Plaintiff's Attorney, if any) (Signature of Defendant's Attorney, if any)
[Add additional signature lines for any additional parties and attorneys.]
I, (Name of ADR Practitioner) agree to conduct the
following ADR in the above-captioned case [check one]:
mediation in accordance with Rules 17-103 and 17-105
ADR other than mediation - specify type:
At the conclusion of the ADR, I agree to comply with the provisions of Rule 17-202 (h).
I solemnly affirm under the penalties of perjury that I have the qualifications prescribed by
the following Rules [check all that are true]:
Rule 17-205 (a) [Basic mediation]
Rule 17-205 (b) [Business and Technology]
Rule 17-205 (c) [Economic Issues - Divorce and Annulment]
Rule 17-205 (d) [Health Care Malpractice]
Rule 17-205 (e) [Foreclosure]
Rule 17-206 [ADR other than mediation]
None of the above.
Signature of ADR Practitioner