Plaintiff:

 Plaintiff's counsel:

 Respondent:

 Respondent's counsel:                    

 1.         I have read and understand the "CCCBA Advisory-Avoiding Mediator Bias" and can state that none of those factors would preclude me from serving as a mediator 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 mediation 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