______
______
______
Telephone:______Fax:______
Email:______/ EMPLOYMENT ARBITRATION
CLAIM FORM
File Number:______
(To be assigned by the Forum)
Name and address for Respondent(s):______
______
______
Telephone:______Fax:______
Email:______/ File Date:______
(To be assigned by the Forum)
Claimant(s) states:
______
______
______
______
______
______
______
______
______
______
Calculating the Total Claim Amount:
List Monetary Claim Amount / ______/ Specify amount of money being sought.List Attorney Fees Amount / ______/ If Requested, specify the dollar amount of
attorney fees. SeeRule 12Bof the Code of Procedure.
List Interest Amount / ______/ If Requested, specify the dollar amount of
interest accrued.
List Non-Monetary Claim Amount / ______/ If Requested, specify the value of
non-monetary relief sought.
Add the above figures / ______/
Total Claim Amount
Calculating the Filing Fee:
If you have requested non-monetary relief, your Claim involves at least one (1) Consumer Party as defined by Rule 2L, and your total Claim amount is $74,999 or less, your Filing Fee is $242.00.
If you have not requested non-monetary relief or if your total Claim amount is $75,000 or larger, see the Fee Schedule to determine the Filing Fee based on your total Claim amount.
List the Filing Fee Amount $______.
Select the Method of Payment for the Filing Fee: Check Credit Card
Account Type: Visa MasterCard Discover American Express
Account Number :______Exp.Date: ______
If you are an indigent Consumer Party, you may Requesta waiver of Common Claim fees pursuant to Rule 45.
Arbitration Award:
Do you Request that the Arbitration Award include recovery of Filing Fees and other fees and costs incurred during the arbitration process? Yes No
If there is no Response to the Initial Claim, the Claim will be reviewed by an Arbitrator and an Award may be issued. If a Response is submitted, the Forumwill advise the Parties of the Hearing.
P.O. Box 50191, Minneapolis, MN55405-0191 • Tel: 800-474-2371 • Fax: 866-743-4517 •
Representation Information:
If you are represented and want the Representative to receive all correspondence, list the information below:
Representative's Name:______
Address:______
City:______State:______Zip:______
Telephone:______Fax Number:______Email:______
Claimant's Affidavit of Authenticity:
I, ______, assert, under penalty of perjury, that the facts
(Print Claimant’s Name)
supporting the Claim, the supporting Documents, and the Arbitration Agreement are accurate and
correct.
Claimant’s Signature:______Date:______
Contact Information:
How do you prefer to receive correspondence regarding this Claim? (Please check the appropriate box)
Email *If checked, enter email address here:______
Fax *If checked, enter fax number here:______
Mail *If checked, enter mailing address here:
Address:______
City:______State:______Zip:______
P.O. Box 50191, Minneapolis, MN55405-0191 • Tel: 800-474-2371 • Fax: 866-743-4517 •