Arbitration Service
     of Portland, Inc.

www.arbserve.com
	9830 SW McKenzie St
   Portland, Oregon  97223

503-226-3109
aspdx@hotmail.com

Kevin A. Eike, Administrator/Attorney	

STATEMENT OF CLAIM
(To initiate an arbitration pursuant to a contractual provision
requiring or permitting an ASP arbitration)

	1.	Commencement of Arbitration.  The Claimant identified below hereby initiates arbitration by paying to Arbitration Service of Portland, Inc. (ASP) the required filing fee, by filing with ASP this Statement of Claim, and by serving a copy thereof on the Opposing Party.

	2.	Statement of Claim.  The following summarizes the basis of Claimant's claim, the relief sought, the dollar amount of any money demand, whether interest is claimed, whether attorney's fees are claimed (and, if so, whether based on contract or statute), and, to the extent known by claimant, the Opposing Party's denial or defense thereto:

		(Attach separate sheet if necessary)

	3.	Claimant.  The name, address, and telephone number of Claimant and Claimant's attorney (if any):

		Claimant:						Claimant's Attorney:

Name:							__________________________

Address:							

Telephone:						___________________	
Email:							__________________________

	4.	Opposing Party.  The name, address, and telephone number of Opposing Party (or parties) and its/their attorney (if any):

		Opposing Party:					Attorney:

Name:							_________	

Address:							

Telephone:								

Email:									

		(attach separate sheet to name additional parties)

	5.	Predispute Agreement.  Claimant encloses a copy of the written agreement (or the pertinent portions thereof) that contains the provision requiring arbitration of the above dispute (including the pages thereof that reveal the parties, their signatures, and the arbitration clause that designates ASP).

	6.	Service on Opposing Party.  Claimant acknowledges that ASP arbitration rule 1 requires Claimant to serve on each Opposing Party and each such party's attorney, if known, a copy of this Statement of Claim and a copy of the Predispute Agreement (or the pertinent portions thereof), and that such service can be accomplished by mailing said copies to their last known address or by delivery (pursuant to ASP rule 3A).

	7.	Filing Fee.  Claimant must pay the entire non-refundable filing fee, computed as follows:  if the dollar amount of the dispute does not exceed $250,000, the filing fee is $700 for a two-party dispute, plus $200 for each additional party.  If the dispute exceeds $250,000 but does not exceed $1,000,000, the filing fee is $1,000 for a two-party dispute, plus $300 for each additional party.  If the dispute exceeds $1,000,000, the filing fee is $2,000 for a two-party dispute, plus $500 for each additional party. 
(See Rule 1D for examples.)

Date:  			

Signature of Claimant or Claimant's Attorney:  	

Print signer's name:  	

Representative capacity:  	
				           (Attorney, President, Partner, Party, etc.)

INSTRUCTIONS

	Mail or deliver to ASP:	
1.	This signed Statement of Claim.
2.	A copy of the predispute agreement.
3.	Your filing fee check, payable to
	"Arbitration Service of Portland." 

Mail to each opposing party:
(and to such party's attorney, if known)
1.	A copy of this signed Statement of Claim.
2.	A copy of the predispute agreement.
	statement of claim2024.wpd (8-1-24)