The opinion
MICHAEL N. FEUER, City Attorney
1
KATHLEEN A. KENEALY, Chief Assistant City Attorney – SBN 212289
2 SCOTT MARCUS, Chief, Civil Litigation Branch - SBN 184980
CORY M. BRENTE, Senior Assistant City Attorney – SBN 115453
3 NICHOLAS LAUBER, Deputy City Attorney – SBN 288499
200 North Main Street, 6th Floor, City Hall East
4
Los Angeles, CA 90012
5 Phone No.: (213) 978-7025
Fax No.: (213) 978-8785
6
Email: nicholas.lauber@lacity.org
7
Attorneys for Defendants CITY OF LOS ANGELES, GABRIEL NILY, TED MORSE,
8 EDWIN NELSON, and ALFREDO JIMENEZ-ESCALANTE
9
MICHAEL YAROSHINSKY
10 951 Hillcrest St, Unit 1
El Segundo, CA, 90245
11
(650) 996-3327
12 Email: mikeyaroshinsky@gmail.com
13 Plaintiff & Plaintiff in Pro Per
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15
16
UNITED STATES DISTRICT COURT
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CENTRAL DISTRICT OF CALIFORNIA
18
19 MICHAEL YAROSHINSKY, CASE NO.: CV19-08255-JAK(PD)
Hon. Judge: John A. Konstradt, Ctrm 10B
20 Plaintiff, Mag. Judge: Patricia A. Donahue
21 vs.
22 STIPULATED PROTECTIVE
CITY OF LOS ANGELES ET AL;
ORDER
23
24
Defendants.
25
26
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1. A. PURPOSES AND LIMITATIONS
1
2 Discovery in this action is likely to involve production of confidential,
3
proprietary, or private information for which special protection from public disclosure
4
and from use for any purpose other than prosecuting this litigation may be warranted.
5
6 Accordingly, the parties hereby stipulate to and petition the Court to enter the
7
following Stipulated Protective Order. The parties acknowledge that this Order does
8
not confer blanket protections on all disclosures or responses to discovery and that
9
10 the protection it affords from public disclosure and use extends only to the limited
11
information or items that are entitled to confidential treatment under the applicable
12
legal principles. The parties further acknowledge, as set forth in Section 12.3, below,
13
14 that this Stipulated Protective Order does not entitle them to file confidential
15
information under seal; Civil Local Rule 79-5 sets forth the procedures that must be
16
followed and the standards that will be applied when a party seeks permission from
17
18 the court to file material under seal.
19
20
21 B. GOOD CAUSE STATEMENT
22 This action involves the City of Los Angeles and Los Angeles Police
23
Department officers. Plaintiff is seeking materials and information that Defendants
24
25 the City of Los Angeles (“the City”) and Los Angeles Police Department officers
26 (collectively “Defendants”) maintain as confidential, specifically the police body
27
worn video from the incident date, police in car video from the incident date in the
possession of the City, and police administrative materials, and which Defendants
1
2 believe need special protection from public disclosure and from use for any purpose
3
other than prosecuting this litigation.
4
Defendants assert that the confidentiality of the materials and information
5
6 sought by Plaintiff is recognized by California and federal law, as evidenced inter alia
7
by California Penal Code section 832.7 and Kerr v. United States Dist. Ct. for N.D.
8
Cal., 511 F.2d 192, 198 (9th Cir. 1975), aff'd, 426 U.S. 394 (1976). The City has not
9
10 publicly released the materials and information referenced above except under
11
protective order or pursuant to a court order, if at all. These materials and information
12
are of the type that has been used to initiate disciplinary action against Los Angeles
13
14 Police Department officers, and has been used as evidence in disciplinary
15
proceedings, where the officers’ conduct was considered to be contrary to LAPD
16
policy.
17
18 The City contends that absent a protective order delineating the responsibilities
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of nondisclosure on the part of the parties hereto, there is a specific risk of unnecessary
20
21 and undue disclosure by one or more of the many attorneys, secretaries, law clerks,
22 paralegals and expert witnesses involved in this case, as well as the corollary risk of
23
embarrassment, harassment and professional and legal harm on the part of the LAPD
24
25 officers referenced in the materials and information.
26 The City also contends that the unfettered disclosure of the materials and
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information, absent a protective order, would allow the media to share this
information with potential jurors in the area, impacting the rights of the City herein to
1
2 receive a fair trial.
3
Defendants have subpoenaed Plaintiff’s medical records which are protected
4
by the Health Insurance Portability and Accountability Act (HIPAA) and require
5
6 special protection from public disclosure and from use for any purpose other than
7
prosecuting this action. Plaintiff contends that any medical information contained in
8
the subpoenaed records which is not directly related to Plaintiff’s physical shoulder
9
10 injury is irrelevant to the prosecution of this action and that absent a protective order
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there is a specific risk of unnecessary and undue disclosure which would lead to the
12
unjust annoyance and embarrassment of Plaintiff. Therefore, any documents
13
14 subpoenaed from a health care provider, if filed with the Court, shall be filed under
15
seal, and shall either file a redacted document with the consent of the party who
16
designated the document as confidential or when such measure proves inadequate
17
18 shall seek permission to file the document under seal by filing a motion for leave to
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file under seal.
20
21 Accordingly, to expedite the flow of information, to facilitate the prompt
22 resolution of disputes over confidentiality of discovery materials, to adequately
23
protect information the parties are entitled to keep confidential, to ensure that the
24
25 parties are permitted reasonable necessary uses of such material in preparation for and
26 in the conduct of trial, to address their handling at the end of the litigation, and serve
27
the ends of justice, a protective order for such information is justified in this matter.
It is the intent of the parties that information will not be designated as confidential for
1
2 tactical reasons and that nothing be so designated without a good faith belief that it
3
has been maintained in a confidential, non-public manner, and there is good cause
4
why it should not be part of the public record of this case.
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6
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2. DEFINITIONS
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2.1 Action: [this pending federal law suit].
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10 2.2 Challenging Party: a Party or Non-Party that challenges the
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designation of information or items under this Order.
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2.3 “CONFIDENTIAL” Information or Items: information (regardless of
13
14 how it is generated, stored or maintained) or tangible things that qualify for protection
15
under Federal Rule of Civil Procedure 26(c), and as specified above in the Good
16
Cause Statement.
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18 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as their
19
support staff).
20
21 2.5 Designating Party: a Party or Non-Party that designates information or
22 items that it produces in disclosures or in responses to discovery as
23
“CONFIDENTIAL.”
24
25 2.6 Disclosure or Discovery Material: all items or information, regardless
26 of the medium or manner in which it is generated, stored, or maintained (including,
27
among other things, testimony, transcripts, and tangible things), that are produced or
generated in disclosures or responses to discovery in this matter.
1
2 2.7 Expert: a person with specialized knowledge or experience in a matter
3
pertinent to the litigation who has been retained by a Party or its counsel to serve as
4
an expert witness or as a consultant in this Action.
5
6 2.8 House Counsel: attorneys who are employees of a party to this Action.
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House Counsel does not include Outside Counsel of Record or any other outside
8
counsel.
9
10 2.9 Non-Party: any natural person, partnership, corporation, association, or
11
other legal entity not named as a Party to this action.
12
2.10 Outside Counsel of Record: attorneys who are not employees of a party
13
14 to this Action but are retained to represent or advise a party to this Action and have
15
appeared in this Action on behalf of that party or are affiliated with a law firm which
16
has appeared on behalf of that party, and includes support staff.
17
18 2.11 Party: any party to this Action, including all of its officers, directors,
19
employees, consultants, retained experts, and Outside Counsel of Record (and their
20
21 support staffs).
22 2.12 Producing Party: a Party or Non-Party that produces Disclosure or
23
Discovery Material in this Action.
24
25 2.13 Professional Vendors: persons or entities that provide litigation support
26 services (e.g., photocopying, videotaping, translating, preparing exhibits or
27
demonstrations, and organizing, storing, or retrieving data in any form or medium)
and their employees and subcontractors.
1
2 2.14 Protected Material: any Disclosure or Discovery Material that is
3
designated as “CONFIDENTIAL.”
4
2.15 Receiving Party: a Party that receives Disclosure or Discovery Material
5
6 from a Producing Party.
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3. SCOPE
9
10 The protections conferred by this Stipulation and Order cover not only
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Protected Material (as defined above), but also (1) any information copied or extracted
12
from Protected Material; (2) all copies, excerpts, summaries, or compilations of
13
14 Protected Material; and (3) any testimony, conversations, or presentations by Parties
15
or their Counsel that might reveal Protected Material.
16
Any use of Protected Material at trial shall be governed by the orders of the
17
18 trial judge. This Order does not govern the use of Protected Material at trial.
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4. DURATION
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Even after final disposition of this litigation, the confidentiality obligations
21
22 imposed by this Order shall remain in effect until a Designating Party agrees
23
otherwise in writing or a court order otherwise directs. Final disposition shall be
24
deemed to be the later of (1) dismissal of all claims and defenses in this Action, with
25
26 or without prejudice; and (2) final judgment herein after the completion and
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exhaustion of all appeals, rehearings, remands, trials, or reviews of this Action,
including the time limits for filing any motions or applications for extension of time
1
2 pursuant to applicable law.
3
4
5. DESIGNATING PROTECTED MATERIAL
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6 5.1 Exercise of Restraint and Care in Designating Material for Protection.
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Each Party or Non-Party that designates information or items for protection under this
8
Order must take care to limit any such designation to specific material that qualifies
9
10 under the appropriate standards. The Designating Party must designate for protection
11
only those parts of material, documents, items, or oral or written communications that
12
qualify so that other portions of the material, documents, items, or communications
13
14 for which protection is not warranted are not swept unjustifiably within the ambit of
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this Order.
16
Mass, indiscriminate, or routinized designations are prohibited. Designations
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18 that are shown to be clearly unjustified or that have been made for an improper
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purpose (e.g., to unnecessarily encumber the case development process or to impose
20
21 unnecessary expenses and burdens on other parties) may expose the Designating Party
22 to sanctions.
23
If it comes to a Designating Party’s attention that information or items that it
24
25 designated for protection do not qualify for protection, that Designating Party must
26 promptly notify all other Parties that it is withdrawing the inapplicable designation.
27
5.2 Manner and Timing of Designations. Except as otherwise provided in
this Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise
1
2 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection
3
under this Order must be clearly so designated before the material is disclosed or
4
produced.
5
6 Designation in conformity with this Order requires:
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(a) for information in documentary form (e.g., paper or electronic
8
documents, but excluding transcripts of depositions or other pretrial or trial
9
10 proceedings), that the Producing Party affix at a minimum, the legend
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“CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that
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contains protected material. If only a portion or portions of the material on a page
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14 qualifies for protection, the Producing Party also must clearly identify the protected
15
portion(s) (e.g., by making appropriate markings in the margins).
16
A Party or Non-Party that makes original documents available for inspection
17
18 need not designate them for protection until after the inspecting Party has indicated
19
which documents it would like copied and produced. During the inspection and before
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21 the designation, all of the material made available for inspection shall be deemed
22 “CONFIDENTIAL.” After the inspecting Party has identified the documents it wants
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copied and produced, the Producing Party must determine which documents, or
24
25 portions thereof, qualify for protection under this Order. Then, before producing the
26 specified documents, the Producing Party must affix the “CONFIDENTIAL legend”
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to each page that contains Protected Material. If only a portion or portions of the
material on a page qualifies for protection, the Producing Party also must clearly
1
2 identify the protected portion(s) (e.g., by making appropriate markings in the
3
margins).
4
(b) for testimony given in depositions that the Designating Party identify
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6 the Disclosure or Discovery Material on the record, before the close of the deposition
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all protected testimony.
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(c) for information produced in some form other than documentary and for
9
10 any other tangible items, that the Producing Party affix in a prominent place on the
11
exterior of the container or containers in which the information is stored the legend
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“CONFIDENTIAL.” If only a portion or portions of the information warrants
13
14 protection, the Producing Party, to the extent practicable, shall identify the protected
15
portion(s).
16
5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent
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18 failure to designate qualified information or items does not, standing alone, waive the
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Designating Party’s right to secure protection under this Order for such material.
20
21 Upon timely correction of a designation, the Receiving Party must make reasonable
22 efforts to assure that the material is treated in accordance with the provisions of this
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Order.
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25
26 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS
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6.1 Timing of Challenges. Any Party or Non-Party may challenge a
designation of confidentiality at any time that is consistent with the Court’s
1
2 Scheduling Order.
3
6.2 Meet and Confer. The Challenging Party shall initiate the dispute
4
resolution process under Local Rule 37.1 et seq.
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6 6.3 The burden of persuasion in any such challenge proceeding shall be on
7
the Designating Party. Frivolous challenges, and those made for an improper purpose
8
(e.g., to harass or impose unnecessary expenses and burdens on other parties) may
9
10 expose the Challenging Party to sanctions. Unless the Designating Party has waived
11
or withdrawn the confidentiality designation, all parties shall continue to afford the
12
material in question the level of protection to which it is entitled under the Producing
13
14 Party’s designation until the Court rules on the challenge.
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7. ACCESS TO AND USE OF PROTECTED MATERIAL
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18 7.1 Basic Principles. A Receiving Party may use Protected Material that is
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disclosed or produced by another Party or by a Non-Party in connection with this
20
21 Action only for prosecuting, defending, or attempting to settle this Action. Such
22 Protected Material may be disclosed only to the categories of persons and under the
23
conditions described in this Order. When the Action has been terminated, a Receiving
24
25 Party must comply with the provisions of section 13 below (FINAL DISPOSITION).
26 Protected Material must be stored and maintained by a Receiving Party at a
27
location and in a secure manner that ensures that access is limited to the persons
authorized under this Order.
1
2 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless
3
otherwise ordered by the court or permitted in writing by the Designating Party, a
4
Receiving Party may disclose any information or item designated
5
6 “CONFIDENTIAL” only to:
7
(a) the Receiving Party’s Outside Counsel of Record in this Action, as well
8
as employees of said Outside Counsel of Record to whom it is reasonably necessary
9
10 to disclose the information for this Action;
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(b) the officers, directors, and employees (including House Counsel) of the
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Receiving Party to whom disclosure is reasonably necessary for this Action;
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14 (c) Experts (as defined in this Order) of the Receiving Party to whom
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disclosure is reasonably necessary for this Action and who have signed the
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“Acknowledgment and Agreement to Be Bound” (Exhibit A);
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18 (d) the court and its personnel;
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(e) court reporters and their staff;
20
21 (f) professional jury or trial consultants, mock jurors, and Professional
22 Vendors to whom disclosure is reasonably necessary for this Action and who have
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signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A);
24
25 (g) the author or recipient of a document containing the information or a
26 custodian or other person who otherwise possessed or knew the information;
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(h) during their depositions, witnesses, and attorneys for witnesses, in the
Action to whom disclosure is reasonably necessary provided: (1) the deposing party
1
2 requests that the witness sign the form attached as Exhibit A hereto; and (2) they will
3
not be permitted to keep any confidential information unless they sign the
4
“Acknowledgment and Agreement to Be Bound” (Exhibit A), unless otherwise
5
6 agreed by the Designating Party or ordered by the court. Pages of transcribed
7
deposition testimony or exhibits to depositions that reveal Protected Material may be
8
separately bound by the court reporter and may not be disclosed to anyone except as
9
10 permitted under this Stipulated Protective Order; and
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(i) any mediator or settlement officer, and their supporting personnel,
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mutually agreed upon by any of the parties engaged in settlement discussions.
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14
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8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED IN
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OTHER LITIGATION
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18 If a Party is served with a subpoena or a court order issued in other litigation
19
that compels disclosure of any information or items designated in this Action as
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“CONFIDENTIAL,” that Party must:
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22 (a) promptly notify in writing the Designating Party. Such notification shall
23
include a copy of the subpoena or court order;
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(b) promptly notify in writing the party who caused the subpoena or order
25
26 to issue in the other litigation that some or all of the material covered by the subpoena
27
or order is subject to this Protective Order. Such notification shall include a copy of
this Stipulated Protective Order; and
1
2 (c) cooperate with respect to all reasonable procedures sought to be pursued
3
by the Designating Party whose Protected Material may be affected.
4
If the Designating Party timely seeks a protective order, the Party served with
5
6 the subpoena or court order shall not produce any information designated in this action
7
as “CONFIDENTIAL” before a determination by the court from which the subpoena
8
or order issued, unless the Party has obtained the Designating Party’s permission. The
9
10 Designating Party shall bear the burden and expense of seeking protection in that court
11
of its confidential material and nothing in these provisions should be construed as
12
authorizing or encouraging a Receiving Party in this Action to disobey a lawful
13
14 directive from another court.
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9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE
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18 PRODUCED IN THIS LITIGATION
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(a) The terms of this Order are applicable to information produced by a
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Non-Party in this Action and designated as “CONFIDENTIAL.” Such information
21
22 produced by Non-Parties in connection with this litigation is protected by the
23
remedies and relief provided by this Order. Nothing in these provisions should be
24
construed as prohibiting a Non-Party from seeking additional protections.
25
26 (b) In the event that a Party is required, by a valid discovery request, to
27
produce a Non-Party’s confidential information in its possession, and the Party is
subject to an agreement with the Non-Party not to produce the Non-Party’s
1
2 confidential information, then the Party shall:
3
(1) promptly notify in writing the Requesting Party and the Non-Party
4
that some or all of the information requested is subject to a confidentiality agreement
5
6 with a Non-Party;
7
(2) promptly provide the Non-Party with a copy of the Stipulated
8
Protective Order in this Action, the relevant discovery request(s), and a reasonably
9
10 specific description of the information requested; and
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(3) make the information requested available for inspection by the Non-
12
Party, if requested.
13
14 (c) If the Non-Party fails to seek a protective order from this court within
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14 days of receiving the notice and accompanying information, the Receiving Party
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may produce the Non-Party’s confidential information responsive to the discovery
17
18 request. If the Non-Party timely seeks a protective order, the Receiving Party shall
19
not produce any information in its possession or control that is subject to the
20
21 confidentiality agreement with the Non-Party before a determination by the court.
22 Absent a court order to the contrary, the Non-Party shall bear the burden and expense
23
of seeking protection in this court of its Protected Material.
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25
26 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL
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If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed
Protected Material to any person or in any circumstance not authorized under this
1
2 Stipulated Protective Order, the Receiving Party must immediately (a) notify in
3
writing the Designating Party of the unauthorized disclosures, (b) use its best efforts
4
to retrieve all unauthorized copies of the Protected Material, (c) inform the person or
5
6 persons to whom unauthorized disclosures were made of all the terms of this Order,
7
and (d) request such person or persons to execute the “Acknowledgment and
8
Agreement to Be Bound” that is attached hereto as Exhibit A.
9
10
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11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE
12
PROTECTED MATERIAL
13
14 When a Producing Party gives notice to Receiving Parties that certain
15
inadvertently produced material is subject to a claim of privilege or other protection,
16
the obligations of the Receiving Parties are those set forth in Federal Rule of Civil
17
18 Procedure 26(b)(5)(B). This provision is not intended to modify whatever procedure
19
may be established in an e-discovery order that provides for production without prior
20
21 privilege review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the
22 parties reach an agreement on the effect of disclosure of a communication or
23
information covered by the attorney-client privilege or work product protection, the
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25 parties may incorporate their agreement in the stipulated protective order submitted
26 to the court.
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12. MISCELLANEOUS
1
2 12.1 Right to Further Relief. Nothing in this Order abridges the right of any
3
person to seek its modification by the Court in the future.
4
12.2 Right to Assert Other Objections. By stipulating to the entry of this
5
6 Protective Order no Party waives any right it otherwise would have to object to
7
disclosing or producing any information or item on any ground not addressed in this
8
Stipulated Protective Order. Similarly, no Party waives any right to object on any
9
10 ground to use in evidence of any of the material covered by this Protective Order.
11
12.3 Filing Protected Material. A Party that seeks to file under seal any
12
Protected Material must comply with Civil Local Rule 79-5. Protected Material may
13
14 only be filed under seal pursuant to a court order authorizing the sealing of the specific
15
Protected Material at issue. If a Party's request to file Protected Material under seal is
16
denied by the court, then the Receiving Party may file the information in the public
17
18 record unless otherwise instructed by the court. Any documents that contain Protected
19
Material which are not filed under seal must be redacted to prevent disclosure of the
20
21 Protected Material.
22
23
13. FINAL DISPOSITION
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After the final disposition of this Action, as defined in paragraph 4, within 60
25
26 days of a written request by the Designating Party, each Receiving Party must return
27
all Protected Material to the Producing Party or destroy such material. As used in this
subdivision, “all Protected Material” includes all copies, abstracts, compilations,
1
2 summaries, and any other format reproducing or capturing any of the Protected
3
Material. Whether the Protected Material is returned or destroyed, the Receiving Party
4
must submit a written certification to the Producing Party (and, if not the same person
5
6 or entity, to the Designating Party) by the 60 day deadline that (1) identifies (by
7
category, where appropriate) all the Protected Material that was returned or destroyed
8
and (2)affirms that the Receiving Party has not retained any copies, abstracts,
9
10 compilations, summaries or any other format reproducing or capturing any of the
11
Protected Material. Notwithstanding this provision, Counsel are entitled to retain an
12
archival copy of all pleadings, motion papers, trial, deposition, and hearing
13
14 transcripts, legal memoranda, correspondence, deposition and trial exhibits, expert
15
reports, attorney work product, and consultant and expert work product, even if such
16
materials contain Protected Material. Any such archival copies that contain or
17
18 constitute Protected Material remain subject to this Protective Order as set forth in
19
Section 4 (DURATION).
20
21
22 14. Any violation of this Order may be punished by any and all appropriate
23
measures including, without limitation, contempt proceedings and/or monetary
24
25 sanctions.
26 ///
27
///
2 || ITIS SO STIPULATED, THROUGH COUNSEL OF RECORD.
3
4
5 DATED: June __, 2020 MICHAEL YAROSHINSKY
6
7 By:
8
9 PLAINTIFF AND PLAINTIFF IN PRO PER
10 || DATED: June 15, 2020 MICHAEL N. FEUER, City Attorney
11 KATHLEEN A. KENEALY, Chief Asst. City Attorney
SCOTT MARCUS, Chief, Civil Litigation Branch
12 CORY M. BRENTE, Senior Asst. City Attorney
13
14 By:
15
16 NICHOLAS LAUBER, Deputy City Attorney
Attorneys for Defendants, CITY OF LOS ANGELES,
17 GABRIEL NILY, TED MORSE, EDWIN NELSON and
18 ALFREDO JIMENEZ-ESCALANTE
19
99 || FOR GOOD CAUSE SHOWN, IT IS SO ORDERED.
21
22 SA Livia.
DATED: June 18, 2020 alice Lenakoe_
23 Honorable Patricia Donahue
United States Magistrate Judge
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1
2 EXHIBIT A
3
ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND
4
5
6 I, ___________________________ [print or type full name], of _________________
7
[print or type full address], declare under penalty of perjury that I have read in its
8
entirety and understand the Stipulated Protective Order that was issued by the United
9
10 States District Court for the Central District of California on [date] in the case of
11
___________ [insert formal name of the case and the number and initials
12
assigned to it by the court]. I agree to comply with and to be bound by all the terms
13
14 of this Stipulated Protective Order and I understand and acknowledge that failure to
15
so comply could expose me to sanctions and punishment in the nature of contempt. I
16
solemnly promise that I will not disclose in any manner any information or item that
17
18 is subject to this Stipulated Protective Order to any person or entity except in strict
19
compliance with the provisions of this Order. I further agree to submit to the
20
21 jurisdiction of the United States District Court for the Central District of California
22 for the purpose of enforcing the terms of this Stipulated Protective Order, even if such
23
enforcement proceedings occur after termination of this action. I hereby appoint
24
25 __________________________ [print or type full name] of
26 ____________________________________ [print or type full address and telephone
27
number] as my California agent for service of process in connection with this action
or any proceedings related to enforcement of this Stipulated Protective Order.
1
2
3
Date: ______________________________________
4
City and State where sworn and signed: _________________________________
5
6 Printed name: _______________________________
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Signature: __________________________________
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