Plaintiff:

Plaintiff's counsel:

Respondent:

Respondent's counsel:

1.         I have read and understand the "CCCBA Advisory-Avoiding Arbitrator Bias" and can state that none of those factors would preclude me from serving as an arbitrator in the above matter. 

2.         Is there a present or past relationship, direct or indirect, with any of the people identified in this dispute that might create any concern of bias or impartiality?  

                       NO                      YES (please explain*) 

3.         Are there any other factors that might create a concern about your impartiality, which ought to be disclosed to the parties? 

                       NO                     YES (please explain*) 

            *(If you have had prior contact with a party to the arbitration proceeding or there are other factors which cause concern, please advise whether the prior matter is concluded; how long ago the prior matter was concluded; and, whether the prior matter ended in a manner which would affect your ability to be impartial.)  

                                                                          
Signature  

                               
Date                                            

RETURN BY                     , TO:  
Emily Day, Fee Arbitration Coordinator
Contra Costa County Bar Association
704 Main Street
Martinez, CA  94553