MEDIATOR (Name and Address):

FOR COURT USE ONLY

ADR-100

STATEMENT OF AGREEMENT OR NONAGREEMENT

First

Supplemental

CASE NUMBER:

The mediator must complete, serve, and file this form

within 10 days after conclusion of the mediation, or by an another date set by the court, in all cases 
assigned to mediation under the Civil Action Mediation Program. (Code Civ. Proc., § 1775 et seq.) 
as required by the court in other mediation programs. 

In completing this form, the mediator must not

provide any information beyond what is specifically requested, or 
disclose any settlement terms, confidential communications, mediation conduct, or mediator conclusions or 
impressions. (Evid. Code, § 1115 et seq.)

1.

I was appointed, assigned, or retained as the mediator in this case on (date):

2.

The mediation (check one) 

was not scheduled.

was scheduled but not held.

was held as follows:
(1)
(2)
(3)

Session dates (specify all): 
Number of sessions:

Total length of sessions (hours):

3.

The mediation ended on (date): 

in a full agreement. 

in a partial agreement. 

in nonagreement.

• •

••

a.

b.

c.

a.

b.

c.

4.

The mediation has not yet ended. I submit this form to comply with the court’s requirement to do so by a specified date. 
(Complete the items below. In Civil Action Mediation Programs and where otherwise required by the court, file a supplemental 
Statement of Agreement or Nonagreement within 10 days after the mediation ends or by such other date as the court may set.) 

a. The mediator anticipates that the mediation will be completed by (date): 

NOTICE TO PARTIES: This form does not extend any mediation completion deadline that the court has set.       
You must request any necessary extension from the court.

b. The next mediation session is scheduled for (date): 

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF MEDIATOR)

Form Adopted for Mandatory Use
Judicial Council of California
ADR-100 [Rev. July 1, 2012]

STATEMENT OF AGREEMENT OR NONAGREEMENT

Page 1 of  2

Code of Civil Procedure, § 1775.9
Cal. Rules of Court, rule 3.895
www.courts.ca.gov

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

FAX NO.:

TELEPHONE NO.:

E-MAIL ADDRESS: 

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CASE NAME:

PROOF OF SERVICE OF STATEMENT OF AGREEMENT OR NONAGREEMENT

1.

At the time of service, I was over 18 years of age and not a party to this action.

2.

My residence or business address is:

3.

4.

The fax number or electronic service address from which I served the document is (complete if service was by fax or 
electronic service):

I served the Statement of Agreement or Nonagreement (form ADR-100) on the person or persons below, as follows: 

a. Name of person served

b. Manner of service 
(specify personal, mail, 
fax, or electronic)

c. Physical or mailing address, 
fax number, or electronic service 
address where person was served

d. Date 
of service

e. Time
of service

5.

The form ADR-100 was served by the following means (check and complete all that apply):

Where personal service is indicated in item 4.b., I personally delivered the form ADR-100 to the persons for whom 
personal service is indicated, at the addresses listed in item 4.c. (1) For a party represented by an attorney, delivery was 
made to the attorney or at the attorney's office by leaving the document in an envelope or package clearly labeled to 
identify the attorney being served with a receptionist or an individual in charge of the office, or in a visible location in the 
office between the hours of 9 a.m. and 5 p.m. (2) For a party, delivery was made to the party or by leaving the document 
at the party's residence with some person not younger than 18 years of age between the hours of 8 a.m. and 6 p.m.

Where service by mail is indicated in item 4.b., I enclosed the form ADR-100 in a sealed envelope or package 
addressed to the persons at the addresses in item 4.c. and (specify one):

(1)            deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid.

(2)            placed the envelope for collection and mailing, following our ordinary business practices. I am readily familiar
                 with this business's practice for collecting and processing correspondence for mailing. 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, in a sealed envelope with postage fully prepaid.

I am a resident of or employed in the county where the mailing occurred. The envelope or package was placed in the mail at 
(city and state):

Where fax transmission is indicated in item 4.b., based on an agreement of the parties to accept service by fax 
transmission, I faxed the form ADR-100 to the persons at the fax numbers listed in item 4.c. No error was reported by the 
fax machine that I used. A copy of the record of the fax transmission, which I printed, is attached.

Where electronic service is indicated in item 4.b., I caused the form ADR-100 to be served on the persons at the 
electronic service addresses listed in item 4.c., in accordance with a court order or an agreement of the parties allowing 
electronic service. 

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

.

  a

b.

c.

d.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

ADR-100 [Rev. July 1, 2012]

STATEMENT OF AGREEMENT OR NONAGREEMENT

Page 2 of  2

The names, addresses, and other applicable information about persons served is on Attachment 4.