ARBITRATION DISPOSITION ASSIGNMENT REQUEST FORM

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Notification to all parties:

Please provide the following information, remember be as detailed as possible, failure to

fill out a particular field may invalidate the process, this application, and the arbitration
award. Please do not add in and/or change and/or alter this application, as doing so will
constitute a breach of this agreement, and stripping any rights and/or elections you may
or may not have had prior to the completion of this form.

Please keep in mind that the FEDERAL ARBITRATION ASSOCIATION is a private

organization with the sole responsibility assigning and/or appointing independent
arbitrators who operate independently of the FEDERAL ARBITRATION ASSOCIATION. The
goal and/or aim is that of helping to appoint an experience and independent federal
arbitrator who operates under the FEDERAL ARBITRATION ACT as codified in 9 USC, two
mediate and/or bring about a peaceful resolution to disagreements and conflicts
respecting contracts that include an arbitration as well as commerce clause. That the
parties to the contract will have had to have agreed to the arbitration prior to the
commencement of the arbitrating proceedings. That arbitration proceedings may be had
electronically so as to decrease the inconvenience on the parties, and by doing so
electronically the parties will have to submit their documentation through secured e-mail
electronic portal, which shall be provided at the time of payment is received for the
services.
We thank you in advance....

Application by claimant(’s):

Name of claimant: Full address: Phone Number:

Did you provide proof of if yes check here ☐ if no, check here ☐
service?
Did the responding party(’s) Did the responding party(’s) Did you grant the opposing
have a duty to respond? Explain: provide any response? party(’s) an opportunity to
cure any default?
Was the response provided within
the statute of limitations?
yes☐
yes ☐ no☐ no☐

Please list the addresses of each of the responding parties below (Copy and Paste into fields):
ARBITRATION DISPOSITION ASSIGNMENT REQUEST FORM
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Name:-- Name--
Address: Address
____

Name-- Name--
Address Address

Name Name
Address Address

Name Name
Address Address

Name Name
Address Address

Name Name
Address Address

Name Name
Address Address

Name Name
Address Address

Date of Contract:
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Contract NUMBER ______________________________________________________

Please select all that applies, if there is an associated page number in the contract, please indicate such:

Breech of Agreement ☐

Agreement included an Arbitration clause ☐

Parties have agreed to SAA appointment ☐

matter involves less than 5 parties ☐

Matter involves more than 5 parties ☐

Other (special circumstances):

Claim(s) Describe issue to be arbitrated - please list as many details regarding the party’s:

I hereby state the following:

That there was a prior agreement between the parties, and that this prior agreement required the parties
to communicate with each other, and that said communications required a response by the receiving party.
That each of the parties to this agreement are competent adults, capable of entering into commercial
agreements that contain an arbitration clause as is the case at present, (see: restatement (SECOND) (THIRD) of
contract))). That the arbitration clause contained an opt-out provision, which was not timely exercised. There I
presented the opposing party with this compelled performance agreement whereby the opposing part(’s),
having assented to the agreement by either act(’s), action(’s), inaction(’s), forbearance, conduct, and/or
performances, constituting assent. The contract was not ambiguous, was doable, fair, and was in line with the
decision made by the United States Congress and the Bradley Christopher Stark act, see: P. L. 114 – 31; Where
they found that a similar contract, operating under the same principles as the reference contract herein,
whereby Congress held that the agreement was valid, binding, enforceable, and irrevocable. I only seek
arbitration because I have communicated with the opposing parties on several occasions to no avail. A debt has
been claimed by the opposing party(’s), a debt whereby THE FEDERAL FAIR DEBT COLLECTIONS PROCEDURES
ACT, THE FEDERAL FAIR DEBT COLLECTIONS PRACTICES ACT, grants any debtor the right to demand
verification of debt, placing a duty upon the opposing party i.e. the creditor to respond with a sworn statement
as to the validity, accuracy, and soundness of the alleged debt. In this instance, the duty to respond via sworn
statement (the legal definition intended by Congress for verification is a statement signed under penalty of
perjury and/or otherwise sworn and attested) rested upon the respondents individually. After notices, after
warning, after forbearances, they have not stopped fair debt collection activities respecting my interests as
required by the federal law.

Because of the breach of the agreement by the responding parties, the arbitration clause permits the party
not in default respecting a particular issue to request disposition of arbitration, and seek a final award from the
arbitrator. It is my intent as well as my goal to reach a resolution through arbitration. And I do know that the
arbitrator will not show me favoritism if I should fail to provide proof of default, neither will the arbitrator issue
an amount that is unreasonable respecting the agreement between the parties.
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Please indicate the page number where the arbitration where the parties are in agreement with SAA __

Please indicate the page number where the arbitration clause may be found in the agreement __

Amount of Claim as indicated in contract Punitive $_________________________________

Please indicate the page number where this amount may be found, if more than one page within the contract,
please indicate such: __

Please indicate the breach of agreement additional amount as indicated in the contract, please indicate the page
number where this amount may be found, if more than one within the contract, please indicate such:

$__________________________________________

Indicate the portion of the agreement where the parties have agreed to
this extra amount by referencing the page number here ___

By presenting this application it is agreed by all parties that the ARBITRATION ASSOCIATION, shall have
the authority to assigned at random and independent arbitrator to this matter. That parties have agreed
to the independent federal arbitrator has the authority to render an impartial decision based on the
terms of the contract and the evidence presented at the time of arbitration, and that the parties agree
to be bound by the decision of the arbitrator and estopped from any collateral attacks against the
arbitrator, the arbitration Association, and or the process server of documents whether that party is a
notary or otherwise. The parties agree to forever hold harmless the aforementioned and any of its
arbitrators and/or associated organizations, and agree that decision made by the independent arbitrator
shall be final and binding upon all parties consistent with the policies, procedures and terms associated
with the SAA. The claimant also acknowledges that the entering of any information on this request form
other than what is specifically requested renders the effect of the additional information void of effect
and nullifies the same.

Electronic Signature: s:/ ________________________________