Request And Stipulation For Referral To A Private AlDR Provider {JD-CL-54}

REQUEST AND STIPULATION FOR REFERRAL TO A PRIVATE ALTERNATIVE DISPUTE RESOLUTION (ADR) PROVIDER JD-CL-54 Rev. 3-15 P.B. § 23-67 C.G.S. § 52-235C Instructions for Applicants 1. All counsel or self-represented parties must sign fully completed form. 2. All parties should make and keep a copy for their records. 3. File both parts of this form in the Superior Court Clerk's Office in which your case is pending. STATE OF CONNECTICUT Court Use Only SUPERIOR COURT www.jud.ct.gov ADRPREF *ADRPREF* ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Instructions for Clerk 1. Bring this completed form and the file to the civil/family presiding judge. 2. Notify counsel and self-represented parties of record of the court's decision. Name of case Docket number Judicial District Housing Session Type of case (Check one) Address of court (Number, street, town, state and zip code) Trial list claim filed Claim date: Trial date: Return date Civil Family Housing No Yes If yes: Request And Stipulation All parties request and stipulate that this case shall be submitted to a private Alternative Dispute Resolution provider as follows: 1. Type Of ADR: Other 2. ADR Provider: (Specify Name of ADR Provider Selected By Parties) Provider Number (See Clerk for List) Non-Binding Mediation Binding Arbitration 3. Scope Of ADR: All issues Liability only Damages only Discovery disputes 4. Requested Referral Period: (Not to Exceed Ninety Days) 5. Special Conditions If Any: Plaintiff Counsel/Self-represented party (Signature) (Date) Defendant Counsel/Self-represented party (Signature) (Date) (Signature) (Date) (Signature) (Date) (Signature) (Date) (Signature) (Date) Order The request and stipulation has been reviewed by this court and it is ORDERED that: the above-entitled case is referred to Alternative Dispute Resolution, and all court proceedings are stayed through or until the ADR process is completed, whichever occurs first. (Specify date - Not to exceed ninety days) the above-entitled case is not referred to Alternative Dispute Resolution. The parties are ordered to file an ADR Result Report with the clerk's office no later than five days after the expiration of the above stay. Special Conditions of Order: By the court: (Judge/Clerk) (Date) Distribution: White - Clerk's Office Yellow - Caseflow American LegalNet, Inc. www.FormsWorkFlow.com