Any information provided is used for the sole purpose of screening your appeal for inclusion in the Mediation Program.
Confidential: it will remain confidential and will not be entered in the court docket or file.
Omissions: the court will not deem an omission from this statement to be a waiver or forfeiture of any claim on appeal.
Other parties: each party shall also serve a copy of their completed Mediation Statement Form on all other parties.
Notice of selection: within 15 days of receipt of the Mediation Statement Forms, the court shall notify the parties when a case is selected for mediation.
| Question | Answer |
|---|---|
| Form Name | Mediation Statement Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 50 |
| Avg. time to fill out | 9 min |
| Edition | Rev.10/2017 |
| Issuing agency | Court of Appeal, Sixth Appellate District |
| Where to return | The Clerk of the Court of Appeal |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | Mediation Statement Form, Mediation Statement, Court of Appeal Mediation Statement, Sixth Appellate District Mediation Statement Form |
| Official source | Mediation Statement Form (Rev 10/2017), Court of Appeal, Sixth Appellate District |
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