even stipulated 15 protective orders require good cause showing
How later courts described this case
- even stipulated 15 protective orders require good cause showing
Written by the judges who cited it.
The opinion
1 RACHEL E. KAUFMAN (SBN 259353)
2
KAUFMAN P.A.
400 NW 26th Street
3 Miami, FL 33127
4 Telephone: (305) 469-5881
rachel@kaufmanpa.com
5
Attorney for Plaintiff and the Putative Class
6
7
8
UNITED STATES DISTRICT COURT
9
CENTRAL DISTRICT OF CALIFORNIA
10
11 Jorge Valdes, ) Case No. 8:20-cv-00469-JLS-DFM
)
)
12 Plaintiff, )
13 ) ) ORDER ON
v. ) STIPULATION AND PROPOSED
14 ) PROTECTIVE ORDER
)
15 Preferred Group Properties, Inc., )
)
16 )
Defendants. )
17 )
18
19 1. PURPOSES AND LIMITATIONS
20 Discovery in this action is likely to involve production of confidential,
21 proprietary or private information for which special protection from public
22 disclosure and from use for any purpose other than pursuing this litigation may
23 be warranted. Accordingly, the parties hereby stipulate to and petition the
24 Court to enter the following Stipulated Protective Order. The parties
25 acknowledge that this Order does not confer blanket protections on all
26 disclosures or responses to discovery and that the protection it affords from
27
28
1 public disclosure and use extends only to the limited information or items that
2 are entitled to confidential treatment under the applicable legal principles.
3 2. GOOD CAUSE STATEMENT
4 This action is likely to involve trade secrets, personally identifiable
5 information, customer and pricing lists and other valuable research,
6 development, commercial, financial, technical and/or proprietary information
7
for which special protection from public disclosure and from use for any
8
purpose other than prosecution of this action is warranted. Such confidential
9
and proprietary materials and information consist of, among other things,
10
confidential business or financial information, information regarding
11
confidential business practices, or other confidential research, development, or
12
commercial information (including information implicating privacy rights of
13
third parties), information otherwise generally unavailable to the public, or
14
which may be privileged or otherwise protected from disclosure under state or
15
federal statutes, court rules, case decisions, or common law. Accordingly, to
16
expedite the flow of information, to facilitate the prompt resolution of disputes
17
over confidentiality of discovery materials, to adequately protect information
18
the parties are entitled to keep confidential, to ensure that the parties are
19
permitted reasonable necessary uses of such material in preparation for and in
20
21 the conduct of trial, to address their handling at the end of the litigation, and
22 serve the ends of justice, a protective order for such information is justified in
23 this matter. It is the intent of the parties that information will not be designated
24 as confidential for tactical reasons and that nothing be so designated without a
25 good faith belief that it has been maintained in a confidential, non-public
26 manner, and there is good cause why it should not be part of the public record
27 of this case.
28
1
2 3. ACKNOWLEDGMENT OF UNDER SEAL FILING
3 PROCEDURE
4 The parties further acknowledge, as set forth in Section 14.3, below, that
5 this Stipulated Protective Order does not entitle them to file confidential
6 information under seal; Local Civil Rule 79-5 sets forth the procedures that
7
must be followed and the standards that will be applied when a party seeks
8
permission from the court to file material under seal. There is a strong
9
presumption that the public has a right of access to judicial proceedings and
10
records in civil cases. In connection with non-dispositive motions, good cause
11
must be shown to support a filing under seal. See Kamakana v. City and
12
County of Honolulu, 447 F.3d 1172, 1176 (9th Cir. 2006), Phillips v. Gen.
13
Motors Corp., 307 F.3d 1206, 1210-11 (9th Cir. 2002), Makar-Welbon v. Sony
14
Electrics, Inc., 187 F.R.D. 576, 577 (E.D. Wis. 1999) (even stipulated
15
protective orders require good cause showing), and a specific showing of good
16
cause or compelling reasons with proper evidentiary support and legal
17
justification, must be made with respect to Protected Material that a party
18
seeks to file under seal. The parties’ mere designation of Disclosure or
19
Discovery Material as CONFIDENTIAL does not— without the submission
20
21 of competent evidence by declaration, establishing that the material sought to
22 be filed under seal qualifies as confidential, privileged, or otherwise
23 protectable—constitute good cause.
24 Further, if a party requests sealing related to a dispositive motion or trial,
25 then compelling reasons, not only good cause, for the sealing must be shown,
26 and the relief sought shall be narrowly tailored to serve the specific interest to
27 be protected. See Pintos v. Pacific Creditors Ass’n., 605 F.3d 665, 677-79 (9th
28 Cir. 2010). For each item or type of information, document, or thing sought to
1 be filed or introduced under seal, the party seeking protection must articulate
2 compelling reasons, supported by specific facts and legal justification, for the
3 requested sealing order. Again, competent evidence supporting the application
4 to file documents under seal must be provided by declaration.
5 Any document that is not confidential, privileged, or otherwise
6 protectable in its entirety will not be filed under seal if the confidential portions
7
can be redacted. If documents can be redacted, then a redacted version for
8
public viewing, omitting only the confidential, privileged, or otherwise
9
protectable portions of the document, shall be filed. Any application that seeks
10
to file documents under seal in their entirety should include an explanation of
11
why redaction is not feasible.
12
4. DEFINITIONS
13
4.1 Action: Valdes v. Preferred Group Properties, Inc., No. 8:20-cv-00469-
14
JLS-DFM (C.D. Cal.).
15
4.2 Challenging Party: a Party or Non-Party that challenges the
16
designation of information or items under this Order.
17
4.3 “CONFIDENTIAL” Information or Items: information
18
(regardless of how it is generated, stored or maintained) or tangible things that
19
qualify for protection under Federal Rule of Civil Procedure 26(c), and as
20
21 specified above in the Good Cause Statement.
22 4.4 Counsel: Outside Counsel of Record and House Counsel (as well
23 as their support staff).
24 4.5 Designating Party: a Party or Non-Party that designates
25 information or items that it produces in disclosures or in responses to discovery
26 as “CONFIDENTIAL.”
27 4.6 Disclosure or Discovery Material: all items or information,
28 regardless of the medium or manner in which it is generated, stored, or
1 maintained (including, among other things, testimony, transcripts, and tangible
2 things), that are produced or generated in disclosures or responses to discovery.
3 4.7 Expert: a person with specialized knowledge or experience in a
4 matter pertinent to the litigation who has been retained by a Party or its
5 counsel to serve as an expert witness or as a consultant in this Action.
6 4.8 House Counsel: attorneys who are employees of a party to this
7
Action. House Counsel does not include Outside Counsel of Record or any
8
other outside counsel.
9
4.9 Non-Party: any natural person, partnership, corporation,
10
association or other legal entity not named as a Party to this action.
11
4.10 Outside Counsel of Record: attorneys who are not employees of a
12
party to this Action but are retained to represent a party to this Action and
13
have appeared in this Action on behalf of that party or are affiliated with a law
14
firm that has appeared on behalf of that party, and includes support staff.
15
4.11 Party: any party to this Action, including all of its officers,
16
directors, employees, consultants, retained experts, and Outside Counsel of
17
Record (and their support staffs).
18
4.12 Producing Party: a Party or Non-Party that produces Disclosure or
19
Discovery Material in this Action.
20
21 4.13 Professional Vendors: persons or entities that provide litigation
22 support services (e.g., photocopying, videotaping, translating, preparing
23 exhibits or demonstrations, and organizing, storing, or retrieving data in any
24 form or medium) and their employees and subcontractors.
25 4.14 Protected Material: any Disclosure or Discovery Material that is
26 designated as “CONFIDENTIAL.”
27 4.15 Receiving Party: a Party that receives Disclosure or Discovery
28 Material from a Producing Party.
1 5. SCOPE
2 The protections conferred by this Stipulation and Order cover not only
3 Protected Material (as defined above), but also (1) any information copied or
4 extracted from Protected Material; (2) all copies, excerpts, summaries, or
5 compilations of Protected Material; and (3) any testimony, conversations, or
6 presentations by Parties or their Counsel that might reveal Protected Material.
7
Any use of Protected Material at trial shall be governed by the orders of
8
the trial judge and other applicable authorities. This Order does not govern the
9
use of Protected Material at trial.
10
6. DURATION
11
Once a case proceeds to trial, information that was designated as
12
CONFIDENTIAL or maintained pursuant to this protective order used or
13
introduced as an exhibit at trial becomes public and will be presumptively
14
available to all members of the public, including the press, unless compelling
15
reasons supported by specific factual findings to proceed otherwise are made to
16
the trial judge in advance of the trial. See Kamakana, 447 F.3d at 1180-81
17
(distinguishing “good cause” showing for sealing documents produced in
18
discovery from “compelling reasons” standard when merits-related documents
19
are part of court record). Accordingly, the terms of this protective order do not
20
21 extend beyond the commencement of the trial.
22 7. DESIGNATING PROTECTED MATERIAL
23 7.1 Exercise of Restraint and Care in Designating Material for
24 Protection. Each Party or Non-Party that designates information
25 or items for protection under this Order must take care to limit any such
26 designation to specific material that qualifies under the appropriate standards.
27 The Designating Party must designate for protection only those parts of
28 material, documents, items or oral or written communications that qualify so
1 that other portions of the material, documents, items or communications for
2 which protection is not warranted are not swept unjustifiably within the ambit
3 of this Order.
4 Mass, indiscriminate or routinized designations are prohibited.
5 Designations that are shown to be clearly unjustified or that have been made
6 for an improper purpose (e.g., to unnecessarily encumber the case development
7
process or to impose unnecessary expenses and burdens on other parties) may
8
expose the Designating Party to sanctions.
9
If it comes to a Designating Party’s attention that information or items
10
that it designated for protection do not qualify for protection, that Designating
11
Party must promptly notify all other Parties that it is withdrawing the
12
inapplicable designation.
13
7.2 Manner and Timing of Designations. Except as otherwise
14
provided in this Order, or as otherwise stipulated or ordered, Disclosure of
15
Discovery Material that qualifies for protection under this Order must be
16
clearly so designated before the material is disclosed or produced.
17
Designation in conformity with this Order requires:
18
(a) for information in documentary form (e.g., paper or electronic
19
documents, but excluding transcripts of depositions or other pretrial or trial
20
21 proceedings), that the Producing Party affix at a minimum, the legend
22 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page
23 that contains protected material. If only a portion of the material on a page
24 qualifies for protection, the Producing Party also must clearly identify the
25 protected portion(s) (e.g., by making appropriate markings in the margins).
26 A Party or Non-Party that makes original documents available for
27 inspection need not designate them for protection until after the inspecting
28 Party has indicated which documents it would like copied and produced.
1 During the inspection and before the designation, all of the material made
2 available for inspection shall be deemed “CONFIDENTIAL.” After the
3 inspecting Party has identified the documents it wants copied and produced,
4 the Producing Party must determine which documents, or portions thereof,
5 qualify for protection under this Order. Then, before producing the specified
6 documents, the Producing Party must affix the “CONFIDENTIAL legend” to
7
each page that contains Protected Material. If only a portion of the material on
8
a page qualifies for protection, the Producing Party also must clearly identify
9
the protected portion(s) (e.g., by making appropriate markings in the margins).
10
(b) for testimony given in depositions that the Designating Party
11
identifies the Disclosure or Discovery Material on the record, before the close
12
of the deposition all protected testimony.
13
(c) for information produced in some form other than
14
documentary and for any other tangible items, that the Producing Party affix
15
in a prominent place on the exterior of the container or containers in which the
16
information is stored the legend “CONFIDENTIAL.” If only a portion or
17
portions of the information warrants protection, the Producing Party, to the
18
extent practicable, shall identify the protected portion(s).
19
7.3 Inadvertent Failures to Designate. If timely corrected, an
20
21 inadvertent failure to designate qualified information or items does not,
22 standing alone, waive the Designating Party’s right to secure protection under
23 this Order for such material. Upon timely correction of a designation, the
24 Receiving Party must make reasonable efforts to assure that the material is
25 treated in accordance with the provisions of this Order.
26
27
28
1 8. CHALLENGING CONFIDENTIALITY DESIGNATIONS
2 8.1. Timing of Challenges. Any Party or Non-Party may challenge a
3 designation of confidentiality at any time that is consistent with the Court’s
4 Scheduling Order.
5 8.2 Meet and Confer. The Challenging Party shall initiate the dispute
6 resolution process under Local Rule 37-1 et seq.
7
8.3 Joint Stipulation. Any challenge submitted to the Court shall be via a
8
joint stipulation pursuant to Local Rule 37-2.
9
8.4 The burden of persuasion in any such challenge proceeding shall be
10
on the Designating Party. Frivolous challenges, and those made for an
11
improper purpose (e.g., to harass or impose unnecessary expenses and burdens
12
on other parties) may expose the Challenging Party to sanctions. Unless the
13
Designating Party has waived or withdrawn the confidentiality designation, all
14
parties shall continue to afford the material in question the level of protection
15
to which it is entitled under the Producing Party’s designation until the Court
16
rules on the challenge.
17
18 9. ACCESS TO AND USE OF PROTECTED MATERIAL
19 9.1 Basic Principles. A Receiving Party may use Protected Material that
20 is disclosed or produced by another Party or by a Non-Party in connection
21
with this Action only for prosecuting, defending or attempting to settle this
22
Action. Such Protected Material may be disclosed only to the categories of
23
persons and under the conditions described in this Order. When the Action has
24
been terminated, a Receiving Party must comply with the provisions of section
25
15 below (FINAL DISPOSITION).
26
27
28
1 Protected Material must be stored and maintained by a Receiving Party
2 at a location and in a secure manner that ensures that access is limited to the
3 persons authorized under this Order.
4 9.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless
5 otherwise ordered by the court or permitted in writing by the Designating
6 Party, a Receiving Party may disclose any information or item designated
7
“CONFIDENTIAL” only to:
8
(a) the Receiving Party’s Outside Counsel of Record in this
9
Action, as well as employees of said Outside Counsel of Record to whom it is
10
reasonably necessary to disclose the information for this Action;
11
(b) the officers, directors, and employees (including House
12
Counsel) of the Receiving Party to whom disclosure is reasonably necessary
13
for this Action;
14
(c) Experts (as defined in this Order) of the Receiving Party to
15
whom disclosure is reasonably necessary for this Action and who have signed
16
the “Acknowledgment and Agreement to Be Bound” (Exhibit A);
17
(d) the court and its personnel;
18
(e) court reporters and their staff;
19
(f) professional jury or trial consultants, mock jurors, and
20
21 Professional Vendors to whom disclosure is reasonably necessary for this
22 Action and who have signed the “Acknowledgment and Agreement to Be
23 Bound” (Exhibit A);
24 (g) the author or recipient of a document containing the
25 information or a custodian or other person who otherwise possessed or knew
26 the information;
27 (h) during their depositions, witnesses, and attorneys for witnesses,
28 in the Action to whom disclosure is reasonably necessary provided: (1) the
1 deposing party requests that the witness sign the form attached as Exhibit A
2 hereto; and (2) they will not be permitted to keep any confidential information
3 unless they sign the “Acknowledgment and Agreement to Be Bound” (Exhibit
4 A), unless otherwise agreed by the Designating Party or ordered by the court.
5 Pages of transcribed deposition testimony or exhibits to depositions that reveal
6 Protected Material may be separately bound by the court reporter and may not
7
be disclosed to anyone except as permitted under this Stipulated Protective
8
Order; and
9
(i) any mediators or settlement officers and their supporting
10
personnel, mutually agreed upon by any of the parties engaged in settlement
11
discussions.
12
10. PROTECTED MATERIAL SUBPOENAED OR ORDERED
13 PRODUCED IN OTHER LITIGATION
14
If a Party is served with a subpoena or a court order issued in other
15
litigation that compels disclosure of any information or items designated in this
16
Action as “CONFIDENTIAL,” that Party must:
17
(a) promptly notify in writing the Designating Party. Such
18
notification shall include a copy of the subpoena or court order;
19
(b) promptly notify in writing the party who caused the subpoena
20
21 or order to issue in the other litigation that some or all of the material covered
22 by the subpoena or order is subject to this Protective Order. Such notification
23 shall include a copy of this Stipulated Protective Order; and
24 (c) cooperate with respect to all reasonable procedures sought to be
25 pursued by the Designating Party whose Protected Material may be affected. If
26 the Designating Party timely seeks a protective order, the Party served with the
27 subpoena or court order shall not produce any information designated in this
28 action as “CONFIDENTIAL” before a determination by the court from which
1 the subpoena or order issued, unless the Party has obtained the Designating
2 Party’s permission. The Designating Party shall bear the burden and expense
3 of seeking protection in that court of its confidential material and nothing in
4 these provisions should be construed as authorizing or encouraging a
5 Receiving Party in this Action to disobey a lawful directive from another court.
6
11. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO
7
BE PRODUCED IN THIS LITIGATION
8
(a) The terms of this Order are applicable to information produced
9
by a Non-Party in this Action and designated as “CONFIDENTIAL.” Such
10
11 information produced by Non-Parties in connection with this litigation is
12 protected by the remedies and relief provided by this Order. Nothing in these
13 provisions should be construed as prohibiting a Non-Party from seeking
14 additional protections.
15 (b) In the event that a Party is required, by a valid discovery
16 request, to produce a Non-Party’s confidential information in its possession,
17 and the Party is subject to an agreement with the Non-Party not to produce the
18 Non-Party’s confidential information, then the Party shall:
19 (1) promptly notify in writing the Requesting Party and the Non-
20 Party that some or all of the information requested is subject to a
21
confidentiality agreement with a Non-Party;
22
(2) promptly provide the Non-Party with a copy of the Stipulated
23
Protective Order in this Action, the relevant discovery request(s), and a
24
reasonably specific description of the information requested; and
25
(3) make the information requested available for inspection by the
26
Non-Party, if requested.
27
(c) If the Non-Party fails to seek a protective order from this court
28
1 within 14 days of receiving the notice and accompanying information, the
2 Receiving Party may produce the Non-Party’s confidential information
3 responsive to the discovery request. If the Non-Party timely seeks a protective
4 order, the Receiving Party shall not produce any information in its possession
5 or control that is subject to the confidentiality agreement with the Non-Party
6 before a determination by the court. Absent a court order to the contrary, the
7
Non-Party shall bear the burden and expense of seeking protection in this court
8
of its Protected Material.
9
12. UNAUTHORIZED DISCLOSURE OF PROTECTED
10 MATERIAL
11
If a Receiving Party learns that, by inadvertence or otherwise, it has
12
disclosed Protected Material to any person or in any circumstance not
13
authorized under this Stipulated Protective Order, the Receiving Party must
14
immediately (a) notify in writing the Designating Party of the unauthorized
15
disclosures, (b) use its best efforts to retrieve all unauthorized copies of the
16
Protected Material, (c) inform the person or persons to whom unauthorized
17
disclosures were made of all the terms of this Order, and (d) request such
18
person or persons to execute the “Acknowledgment an Agreement to Be
19
Bound” attached hereto as Exhibit A.
20
21 13. INADVERTENT PRODUCTION OF PRIVILEGED OR
OTHERWISE PROTECTED MATERIAL
22
23 When a Producing Party gives notice to Receiving Parties that certain
24 inadvertently produced material is subject to a claim of privilege or other
25 protection, the obligations of the Receiving Parties are those set forth in
26 Federal Rule of Civil Procedure 26(b)(5)(B). This provision is not intended to
27 modify whatever procedure may be established in an e-discovery order that
28 provides for production without prior privilege review. Pursuant to Federal
1 Rule of Evidence 502(d) and (e), insofar as the parties reach an agreement on
2 the effect of disclosure of a communication or information covered by the
3 attorney-client privilege or work product protection, the parties may
4 incorporate their agreement in the stipulated protective order submitted to the
5 court.
6 14. MISCELLANEOUS
7
14.1 Right to Further Relief. Nothing in this Order abridges the right of
8
any person to seek its modification by the Court in the future.
9
14.2 Right to Assert Other Objections. By stipulating to the entry of this
10
Protective Order, no Party waives any right it otherwise would have to object
11
to disclosing or producing any information or item on any ground not
12
addressed in this Stipulated Protective Order. Similarly, no Party waives any
13
right to object on any ground to use in evidence of any of the material covered
14
by this Protective Order.
15
14.3 Filing Protected Material. A Party that seeks to file under seal any
16
Protected Material must comply with Local Civil Rule 79-5. Protected
17
Material may only be filed under seal pursuant to a court order authorizing the
18
sealing of the specific Protected Material. If a Party’s request to file Protected
19
Material under seal is denied by the court, then the Receiving Party may file
20
21 the information in the public record unless otherwise instructed by the court.
22 15. FINAL DISPOSITION
23 After the final disposition of this Action, as defined in paragraph 6,
24 within 60 days of a written request by the Designating Party, each Receiving
25 Party must return all Protected Material to the Producing Party or destroy such
26 material. As used in this subdivision, “all Protected Material” includes all
27 copies, abstracts, compilations, summaries, and any other format reproducing
28 or capturing any of the Protected Material. Whether the Protected Material is
1 returned or destroyed, the Receiving Party must submit a written certification
2 to the Producing Party (and, if not the same person or entity, to the
3 Designating Party) by the 60-day deadline that (1) identifies (by category,
4 where appropriate) all the Protected Material that was returned or destroyed
5 and (2) affirms that the Receiving Party has not retained any copies, abstracts,
6 compilations, summaries or any other format reproducing or capturing any of
7
the Protected Material. Notwithstanding this provision, Counsel are entitled to
8
retain an archival copy of all pleadings, motion papers, trial, deposition, and
9
hearing transcripts, legal memoranda, correspondence, deposition and trial
10
exhibits, expert reports, attorney work product, and consultant and expert
11
work product, even if such materials contain Protected Material. Any such
12
archival copies that contain or constitute Protected Material remain subject to
13
this Protective Order as set forth in Section 6 (DURATION).
14
16. VIOLATION
15
Any violation of this Order may be punished by appropriate measures
16
including, without limitation, contempt proceedings and/or monetary
17
sanctions.
18
IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD.
19
20
21
Dated: October 7, 2020 By: /s/ Rachel E. Kaufman
22 Rachel E. Kaufman
rachel@kaufmanpa.com
23
KAUFMAN P.A.
24 400 NW 26th Street
25 Miami, FL 33127
Telephone: (305) 469-5881
26
27 Counsel for Plaintiff and all others similarly
situated
28
1
2
3
Dated: October 7, 2020 By: /s/ Stephen H. Turner
4 Stephen H. Turner
5 stephen.turner@lewisbrisbois.com
LEWIS BRISBOIS BISGAARD & SMITH
6 LLP
7 633 W. 5" Street, Suite 4000
Los Angeles, CA 90071
8 (213) 250-1800
9
10 Counsel for Defendant Harcourts Prime
Properties
i ATTESTATION PURSUANT TO LOCAL RULE 5-4.3.4(2)(i)
12 Pursuant to Local Rule 5-4.3.4(2)(i), I, Rachel Kaufman, attest that all other
signatories listed and on whose behalf the filing is submitted concur in this filing’s
14
content and have authorized this filing.
15
16
17 By: /s/Rachel E. Kaufman
8 Rachel E. Kaufman
19
20
FOR GOOD CAUSE SHOWN, IT IS SO ORDERED.
22
93 || DATED: October 8, 2020
24 □
25 —_
DOUGLAS F. McCORMICK
United States Magistrate Judge
27
28
16
1 EXHIBIT A
ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND
2
3
I, [print or type full name], of
4
[print or type full address], declare under penalty of perjury that I have
5
read in its entirety and understand the Stipulated Protective Order that was issue by the
6
7 United States District Court for the Central District of California on [DATE] in the case
8 of Valdes v. Preferred Group Properties, Inc., No. 8:20-cv-00469-JLS-DFM. I agree
9
to comply with and to be bound by all the terms of this Stipulated Protective Order and I
10
understand and acknowledge that failure to so comply could expose me to sanctions and
11
12 punishment in the nature of contempt. I solemnly promise that I will not disclose in any
13 manner any information or item that is subject to this Stipulated Protective Order to any
14 person or entity except in strict compliance with the provisions of this Order.
15
I further agree to submit to the jurisdiction of the United States District Court for
16
the Central District of California for the purpose of enforcing the terms of this Stipulated
17
Protective Order, even if such enforcement proceedings occur after termination of this
18
19 action. I hereby appoint [print or type full name] of
20 [print or type full address and telephone number] as my
21 California agent for service of process in connection with this action or any proceedings
22
related to enforcement of this Stipulated Protective Order.
23
Date:
24
City and State where sworn and signed:
25
26 Printed Name:
27 Signature:
28