REFEREE   (Name, State Bar number, if applicable, and address):

ADR-111

FOR COURT USE ONLY

SUPERIOR COURT OF CALIFORNIA, COUNTY OF 

FAX NO. (Optional):

TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER/PLAINTIFF: 

RESPONDENT/DEFENDANT:

1. Appointment. The undersigned referee was appointed as follows:

a.
b.

Date. By order dated:   
Statutory authority. Referee was appointed under (check one):

(1)
(2)

Code of Civil Procedure section 638.
Code of Civil Procedure section 639.

REPORT OF REFEREE

CASE  NUMBER:

2. Submission. The hearing, if any, was concluded and the matter was submitted on (date):  

3.  Referee's time and fees. (All items must be completed if referee was appointed under section 639.)

a. Total hours spent by referee:   
b. Total fees charged by referee:  
c. Referee recommends the following allocation of payment of referee's fees (state the recommended allocation below or in 

Attachment 3c):

4. Recommendation on the merits. (State the recommendation on the merits of any disputed issues below or in Attachment 4.)   

5. Pages and attachments. Number of pages attached:    

Date:

(NAME OF REFEREE)

(SIGNATURE OF  REFEREE)

Form Approved for Optional Use
Judicial Council of California
ADR-111 [New January 1, 2006]

REPORT OF REFEREE
(Alternative Dispute Resolution)

Page 1 of 2

Code of Civil Procedure, § 643   

www.courtinfo.ca.gov

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

 CASE NUMBER:

ADR-111

DECLARATION OF SERVICE OF REPORT OF REFEREE

1.   I am at least 18 years of age, not a party to this action, and I am a resident of or employed in the county where the mailing took 

place.  

2.   My residence or business address is:

3.   I served a copy of the Report of Referee (Alternative Dispute Resolution) (form ADR-111) by enclosing it in a sealed envelope 

with postage fully prepaid, as follows:

a.

b.

I deposited the sealed envelope with the United States Postal Service with the postage fully prepaid.
I placed the envelope for collection and processing for mailing following this business's ordinary practice with which I 
am readily familiar.  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.

c. Date of deposit:    
d. Place of deposit (city and state):   
e. Addressed as follows (name and address of each party): 

4.   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)

ADR-111 [New January 1, 2006]

Page 2 of 2

REPORT OF REFEREE
(Alternative Dispute Resolution)