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00-'oz�7 Society of St. Vincent de Paul <br />Institute for Conflict Management <br />❑ Mediation ❑ Conciliation <br />Case # Date: Location: <br />A) As a result of this mediation I, will be responsible for <br />1) Financial Restitution: I will make total restitution in the amount of S <br />This payment will be made: <br />in one payment due on <br />77 in several payments made in the amount of 5 <br />or <br />beginning on and ending on <br />Lj Payment(s) must be made to the City of Santa Ana with the account number #68 -01 -5627 written on the face of the <br />payment. <br />n Payment must be made to <br />Payments must be made by check or money order and mailed (or delivered) to the 1CM office at 2525 North Grand Ave., <br />Suite N, Santa Ana, CA 92705. <br />2) Pay the 1CM Program Fee: I agree to pay the $45.00 program fee. I will send a check or money order to the JCM <br />office at 2525 North Grand Ave., Suite N, Santa Ana, CA 92705, payable to ICM. This payment will be made: <br />0 in one payment due on - or <br />in several payments made in the amount of $ beginning on and <br />ending on _ <br />3) Complete Community Service: I agree to complete community service hours fur the City of Santa <br />Ana . Community service hours will begin on _ , and must be completed by <br />will go to an orientation meeting : Orientation is on Thursday at 5:30pm, Santa Ana Senior Center, 424 <br />West 3rd St., near Ross. 1 will bring this document to the orientation meeting. <br />4) — <br />B) As a result of this mediation, it is agreed that upon the completion of the terms listed above, the Santa Ana Police <br />Department will not file charges regarding this incident, or pursue further claims against <br />A copy of this agreement will be sent back to the law enforcement agency (probation, Police, etc) which referred the case to ICM. Failure <br />to abide by the terms of this agreement will result in civil action being taken against the offender andlor their guardian, for the unpaid <br />restitution and the offender being referred to the Criminal Court for prosecution. <br />Please sign your name here <br />1) Sign: <br />2) Sign: <br />3) Sign: <br />4) Sign: <br />5) Sign: <br />9 I; <br />Initial here if you agree to waive the confidentiality of <br />this agreement provided under California Evidence Code <br />Section 1115 -1128. Your initial here would allow this <br />agreement to be admitted as evidence in civil court. <br />11 21 3) <br />41 51 6) <br />Please print your name here <br />St. Vincent do Paul Cenlerfor Community Reconciliation <br />2525 North Grand Avenue, Suite N <br />Santat Ana, CA 92705 -8725 <br />Telephone: 714 -288 -5600, Fax: 714- 288 -5619 <br />email: vorpoc(�gc.ape.org <br />http l /members. aol. com/CnflictMgt <br />�omu,nn.vwna :msacom.da ,e.mion 31158 <br />