Pro-Standards – Form A21 – Arbitration Disclosure IVAR Assigned Case #:(Required)Complainant:(Required)Complainant Legal Counsel:Respondent:(Required)Respondent Legal Counsel:Disclosure of proposed Neutral Arbitrator: Please check the appropriate boxes.1. Are you or a member of your extended family a party, a party’s spouse or domestic partner, or an officer, director, or trustee of a party?(Required) Yes No 2A. Are you or a member of your extended family, or your former spouse a lawyer in the arbitration?(Required) Yes No 2B. Are you or a member of your extended family, or your former spouse the spouse or domestic partner of a lawyer in the arbitration?(Required) Yes No 2C. Are you or a member of your extended family, or your former spouse currently associated in the private practice of law with a lawyer in the arbitration?(Required) Yes No 3. Have you or a member of your immediate family had a significant personal relationship with any party, lawyer for a party or any lawyer currently practicing law with an attorney for a party?(Required) Yes No 4. Are you serving or, within the preceding five (5) years, have you served as a neutral arbitrator in another arbitration involving a party to the current arbitration, a lawyer for a party or other lawyer currently practicing law with an attorney for a party?(Required) Yes No File Drop files here or Select files Max. file size: 20 MB. Please attach a separate sheet disclosing the following for each such previous case: (1) identification of all parties to the case; (2) identification of all parties’ attorneys; (3) identification of the prevailing party; (4) the amount of the award, if any and (5) the date of the arbitration award. It is sufficient to give the name of any party who is not a party to the pending arbitration as “complainant” or “respondent” if the party is an individual and not a business or corporate entity.5. Are you serving or, within the preceding five (5) years, have you served as a party-appointed arbitrator in another arbitration for either a party to the current arbitration, a lawyer for a party or other lawyer currently practicing law with an attorney for a party?(Required) Yes No File Drop files here or Select files Max. file size: 20 MB. Please attach a separate sheet disclosing the following for each such previous case: (1) identification of all parties to the case; (2) identification of all parties’ attorneys; (3) identification of the prevailing party; (4) the amount of the award, if any and (5) the date of the arbitration award. It is sufficient to give the name of any party who is not a party to the pending arbitration as “complainant” or “respondent” if the party is an individual and not a business or corporate entity. If the combined total of the cases disclosed under (4), and (5) is greater than five, you must provide a summary that states the total number of cases in which you served in each capacity and the number of cases in which the party to the current arbitration or the party represented by the lawyer for a party in the current arbitration was the prevailing party.6. Are you serving or have you served as a (1) temporary judge under article VI, section 21 of the California Constitution, (2) referee under CCP Sec. 638-639, (3) neutral evaluator, (4) special master, (4) mediator, (5) settlement officer or (6) settlement facilitator in another pending or prior case involving a party or lawyer in the current arbitration or a lawyer who is currently associated in the private practice of law with a lawyer in the arbitration.?(Required) Yes No File Drop files here or Select files Max. file size: 20 MB. If you were or will be paid for serving in such a capacity, you must disclose on a separate sheet: (i) the number of pending and prior cases in which you were or will be paid for serving in each capacity for each party, lawyer in the arbitration, or other lawyer currently associated in the private practice of law with a lawyer in the arbitration; and (ii) in each such case in which you rendered a decision as a temporary judge or referee, the date of the decision, the prevailing party, the names of the parties’ attorneys, and the amount of monetary damages awarded, if any. If the total of the cases disclosed under this question is greater than five (5), you must also provide a summary that states the number of cases in which you rendered a decision as a temporary judge or referee in which the party to the current arbitration or the party represented by the lawyer in the current arbitration was the prevailing party. (An arbitrator will be deemed to have complied with this requirement with respect to any such services commenced prior to July 1, 2002, if the arbitrator declares in writing that he or she has requested the required information from any dispute resolution provider organization administering those prior services and has disclosed all required information pertaining to those services within his or her knowledge.)7. Do you now have or have you had any attorney-client relationship with a party, lawyer for a party or other lawyer currently practicing law with an attorney for a party?(Required) Yes No Attorney-client relationships include the following: a) A party or an officer, a director, or a trustee of a party is or was your client in your private practice of law or a client of a lawyer with whom you are or were associated in the private practice of law; b) A lawyer for a party is or was a your client in your private practice of law; and c) In any other proceeding involving the same issues, you gave advice to a party or a lawyer in the arbitration concerning any matter involved in this arbitration.8. Do you or a member of your immediate family have or have you had any other professional relationship with a party, lawyer for a party or other lawyer currently practicing law with an attorney for a party?(Required) Yes No Professional relationships include the following: a) You or a member of your immediate family is or was an employee of or an expert witness or a consultant for a party; b) You or a member of your immediate family is or was an employee of or an expert witness or a consultant for a lawyer in the arbitration; and c) You are or were associated in the private practice of law with a lawyer in the arbitration.9. Do you or a member of your immediate family have a financial interest in a party?(Required) Yes No 10. Do you or a member of your immediate family have a financial interest in the subject matter of the arbitration?(Required) Yes No 11. Do you or a member of your immediate family have an interest that could be substantially affected by the outcome of the arbitration?(Required) Yes No 12. Do you or a member of your extended family have personal knowledge of disputed evidentiary facts relevant to the arbitration?(Required) Yes No ( A person who is likely to be a material witness in the proceeding is deemed to have personal knowledge of disputed evidentiary facts concerning the proceeding.)13. Are you a member of any organization that practices invidious discrimination on the basis of race, sex, religion, national origin, or sexual orientation?(Required) Yes No (Membership in a religious organization, an official military organization of the United States, or a nonprofit youth organization need not be disclosed unless it would interfere with your proper conduct of the proceeding or would cause a person aware of the fact to reasonably entertain a doubt concerning your ability to act impartially.)14A. Are you aware of any other matter that might cause a person aware of the facts to reasonably entertain a doubt that you would be able to be impartial?(Required) Yes No 14B. Are you aware of any other matter that leads you to believe there is a substantial doubt as to your capacity to be impartial, including, but not limited to, bias or prejudice toward a party, lawyer, or law firm in the arbitration?(Required) Yes No 14C. Are you aware of any other matter that otherwise leads you to believe that your disqualification will further the interests of justice?(Required) Yes No 15. Is there any reason you might not be able to properly perceive the evidence or properly conduct the proceedings because of a permanent or temporary physical impairment?(Required) Yes No 16. Do you know of any constraints on your availability that will interfere with your ability to commence or complete the arbitration in a timely manner?(Required) Yes No 17. Is there any other matter, which if disclosed, could cause a person aware of the facts to reasonably entertain a doubt that you would be able to be impartial?(Required) Yes No File Drop files here or Select files Max. file size: 20 MB. Please attach a separate sheet disclosing the matter which provides any and all information regarding the matter to the full extent of your knowledge.Confirmation and Submission:Proposed Neutral Arbitrator:(Required)Arbitrator Email:(Required) Δ
