The opinion
1 S. FRANK HARRELL – SBN 133437
sharrell@lynberg.com
2 G. CRAIG SMITH – SBN 265676
csmith@lynberg.com
GARROS CHAN – SBN 320561
3 gchan@lynberg.com
LYNBERG & WATKINS
4 A Professional Corporation
1100 Town & Country Road, Suite 1450
5 Orange, California 92868
(714) 937-1010 Telephone
(714) 937-1003 Facsimile
6
Attorneys for Defendant, COUNTY OF ORANGE
7
8 UNITED STATES DISTRICT COURT
9 CENTRAL DISTRICT OF CALIFORNIA
10
ROMULA CORTEZ, an individual; Case No. 8:25-cv-01552-FWS(ADS)
11
Plaintiff(s),
12
v. STIPULATED PROTECTIVE ORDER
13
COUNTY OF ORANGE, a California
14 Public entity; City of San Clemente, a
California public entity; and DOES 1-20
15 inclusive
16 Defendant(s).
17 Defendant COUNTY OF ORANGE (“Defendants”) and Plaintiff ROMULA
18 CORTEZ (“Plaintiff”), by and through their attorneys of record hereby stipulate, as
19 follows:
20 I. PURPOSES AND LIMITATIONS
21 A. Discovery in this action is likely to involve production of confidential,
22 proprietary, or private information for which special protection from public
23 disclosure and from use for any purpose other than prosecuting this litigation
24 may be warranted. Accordingly, the parties hereby stipulate to and petition the
1 Court to enter the following Stipulated Protective Order. The parties
2 acknowledge that this Order does not confer blanket protections on all
3 disclosures or responses to discovery and that the protection it affords from
4 public disclosure and use extends only to the limited information or items that
5 are entitled to confidential treatment under the applicable legal principles. The
6 parties further acknowledge, as set forth in Section XIII(C), below, that this
7 Stipulated Protective Order does not entitle them to file confidential information
8 under seal; Civil Local Rule 79-5 sets forth the procedures that must be followed
9 and the standards that will be applied when a party seeks permission from the
10 Court to file material under seal.
11 II. GOOD CAUSE STATEMENT
12 A. This action is likely to involve information which one or more of the
13 parties contend special protection from use for any purpose other than litigation
14 in this action is warranted. Defendant contends that such confidential
15 information includes video footage and/or photographs from within the
16 possession and control of the County containing information possibly pertaining
17 to third parties that are not parties to this lawsuit, and/or containing images of
18 third parties that are not parties to this lawsuit. Such confidential information
19 may also include documents that contain personal and confidential information
20 regarding individuals which information is generally unavailable to the public,
21 including peace officer and/or County employee personnel records. The
22 disclosure of this information to the public may violate these individuals’ privacy
23 rights, and its disclosure may impact the County of Orange’s Sheriff’s
24 Department’s operations and safety. Good cause therefore exists for designating
1 these materials as confidential for Defendant, its employees, and officials to
2 protect government interests, as well as the privacy rights of third parties not
3 subject to this litigation. Accordingly, to expedite the flow of information, to
4 facilitate the prompt resolution of disputes over confidentiality of discovery
5 materials, to adequately protect information the parties are entitled to keep
6 confidential, to ensure that the parties are permitted reasonable necessary uses
7 of such material in preparation for and in the conduct of trial, to address their
8 handling at the end of the litigation, and serve the ends of justice, a protective
9 order for such information is justified in this matter. It is the intent of the
10 parties that information will not be designated as confidential for tactical
11 reasons and that nothing be so designated without a good faith belief that it has
12 been maintained in a confidential, non-public manner, and there is good cause
13 why it should not be part of the public record of this case.
14 III. DEFINITIONS
15 A. Action: [This pending federal law suit]. [*Option: consolidated or related
16 actions.]
17 B. Challenging Party: A Party or Non-Party that challenges the designation
18 of information or items under this Order.
19 C. “CONFIDENTIAL” Information or Items: Information (regardless of how
20 it is generated, stored or maintained) or tangible things that qualify for
21 protection under Federal Rule of Civil Procedure 26(c), and as specified above in
22 the Good Cause Statement.
23 D. Counsel: Outside Counsel of Record and House Counsel (as well as their
24 support staff).
1 E. Designating Party: A Party or Non-Party that designates information or
2 items that it produces in disclosures or in responses to discovery as
3 “CONFIDENTIAL.”
4 F. Disclosure or Discovery Material: All items or information, regardless of
5 the medium or manner in which it is generated, stored, or maintained
6 (including, among other things, testimony, transcripts, and tangible things), that
7 are produced or generated in disclosures or responses to discovery in this
8 matter.
9 G. Expert: A person with specialized knowledge or experience in a matter
10 pertinent to the litigation who has been retained by a Party or its counsel to
11 serve as an expert witness or as a consultant in this Action.
12 H. House Counsel: Attorneys who are employees of a party to this Action.
13 House Counsel does not include Outside Counsel of Record or any other outside
14 counsel.
15 I. Non-Party: Any natural person, partnership, corporation, association, or
16 other legal entity not named as a Party to this action.
17 J. Outside Counsel of Record: Attorneys who are not employees of a party
18 to this Action but are retained to represent or advise a party to this Action and
19 have appeared in this Action on behalf of that party or are affiliated with a law
20 firm which has appeared on behalf of that party, and includes support staff.
21 K. Party: Any party to this Action, including all of its officers, directors,
22 employees, consultants, retained experts, and Outside Counsel of Record (and
23 their support staffs).
24
1 L. Producing Party: A Party or Non-Party that produces Disclosure or
2 Discovery Material in this Action.
3 M. Professional Vendors: Persons or entities that provide litigation support
4 services (e.g., photocopying, videotaping, translating, preparing exhibits or
5 demonstrations, and organizing, storing, or retrieving data in any form or
6 medium) and their employees and subcontractors.
7 N. Protected Material: Any Disclosure or Discovery Material that is
8 designated as “CONFIDENTIAL.”
9 O. Receiving Party: A Party that receives Disclosure or Discovery Material
10 from a Producing Party.
11 IV. SCOPE
12 A. The protections conferred by this Stipulation and Order cover not only
13 Protected Material (as defined above), but also (1) any information copied or
14 extracted from Protected Material; (2) all copies, excerpts, summaries, or
15 compilations of Protected Material; (3) any testimony, conversations, or
16 presentations by Parties or their Counsel that might reveal Protected Material;
17 and (4) if any information, documents, video, photographs, and/or other
18 materials which are the subject of this Protective Order are discussed, in any
19 way, during a deposition, said portion of the deposition transcript shall be
20 treated as confidential material subject to this Protective Order. Protected
21 Material shall be used solely in connection with the preparation and trial of the
22 within case, Case No. 8:25-cv-01552-FWS(ADS), or any related appellate
23 proceeding, and not for any other purpose, including any other litigation.
24
1 B. Any use of Protected Material at trial shall be governed by the orders of
2 the trial judge. This Order does not govern the use of Protected Material at trial.
3 V. DURATION
4 A. Once a case proceeds to trial, unless timely objected to, all trial exhibits
5 that were designated as confidential or maintained pursuant to this Protective
6 Order become public and will be presumptively available to all members of the
7 public, including the press, unless compelling reasons supported by specific
8 factual findings to proceed otherwise are made to the trial judge in advance of
9 the trial. See Kamakana v. City and County of Honolulu, 447 F.3d 1172, 1180-81
10 (9th Cir. 2006) (distinguishing “good cause” showing for sealing documents
11 produced in discovery from “compelling reasons” standard when merits-related
12 documents are part of court record). Any trial exhibit containing the
13 Confidential Designation that is to be used at trial shall be reproduced without
14 the Confidential Designation during the parties’ pretrial disclosures. Even after
15 final disposition of this litigation, the confidentiality obligations imposed by this
16 Order shall remain in effect until a Designating Party agrees otherwise in writing
17 or a court order otherwise directs. Final disposition shall be deemed to be the
18 later of (1) dismissal of all claims and defenses in this Action, with or without
19 prejudice; and (2) final judgment herein after the completion and exhaustion of
20 all appeals, rehearings, remands, trials, or reviews of this Action, including the
21 time limits for filing any motions or applications for extension of time pursuant
22 to applicable law.
23 VI. DESIGNATING PROTECTED MATERIAL
24 A. Exercise of Restraint and Care in Designating Material for Protection
1 1. Each Party or Non-Party that designates information or items for
2 protection under this Order must take care to limit any such designation
3 to specific material that qualifies under the appropriate standards. The
4 Designating Party must designate for protection only those parts of
5 material, documents, items, or oral or written communications that
6 qualify so that other portions of the material, documents, items, or
7 communications for which protection is not warranted are not swept
8 unjustifiably within the ambit of this Order.
9 2. Mass, indiscriminate, or routinized designations are prohibited.
10 Designations that are shown to be clearly unjustified or that have been
11 made for an improper purpose (e.g., to unnecessarily encumber the case
12 development process or to impose unnecessary expenses and burdens on
13 other parties) may expose the Designating Party to sanctions.
14 3. If it comes to a Designating Party’s attention that information or
15 items that it designated for protection do not qualify for protection, that
16 Designating Party must promptly notify all other Parties that it is
17 withdrawing the inapplicable designation.
18 B. Manner and Timing of Designations
19 1. Except as otherwise provided in this Order (see, e.g., Section
20 B(2)(b) below), or as otherwise stipulated or ordered, Disclosure or
21 Discovery Material that qualifies for protection under this Order must be
22 clearly so designated before the material is disclosed or produced.
23 2. Designation in conformity with this Order requires the following:
24
1 a. For information in documentary form (e.g., paper or
2 electronic documents, but excluding transcripts of depositions or
3 other pretrial or trial proceedings), that the Producing Party affix
4 at a minimum, the legend “CONFIDENTIAL” (hereinafter
5 “CONFIDENTIAL legend”), to each page that contains protected
6 material. If only a portion or portions of the material on a page
7 qualifies for protection, the Producing Party also must clearly
8 identify the protected portion(s) (e.g., by making appropriate
9 markings in the margins).
10 b. A Party or Non-Party that makes original documents
11 available for inspection need not designate them for protection
12 until after the inspecting Party has indicated which documents it
13 would like copied and produced. During the inspection and before
14 the designation, all of the material made available for inspection
15 shall be deemed “CONFIDENTIAL.” After the inspecting Party has
16 identified the documents it wants copied and produced, the
17 Producing Party must determine which documents, or portions
18 thereof, qualify for protection under this Order. Then, before
19 producing the specified documents, the Producing Party must affix
20 the “CONFIDENTIAL legend” to each page that contains Protected
21 Material. If only a portion or portions of the material on a page
22 qualifies for protection, the Producing Party also must clearly
23 identify the protected portion(s) (e.g., by making appropriate
24 markings in the margins).
1 c. For testimony given in depositions, that the Designating
2 Party identify the Disclosure or Discovery Material on the record,
3 before the close of the deposition all protected testimony.
4 d. For information produced in form other than document and
5 for any other tangible items, that the Producing Party affix in a
6 prominent place on the exterior of the container or containers in
7 which the information is stored the legend “CONFIDENTIAL.” If
8 only a portion or portions of the information warrants protection,
9 the Producing Party, to the extent practicable, shall identify the
10 protected portion(s).
11 C. Inadvertent Failure to Designate
12 1. If timely corrected, an inadvertent failure to designate qualified
13 information or items does not, standing alone, waive the Designating
14 Party’s right to secure protection under this Order for such material.
15 Upon timely correction of a designation, the Receiving Party must make
16 reasonable efforts to assure that the material is treated in accordance with
17 the provisions of this Order.
18 VII. CHALLENGING CONFIDENTIALITY DESIGNATIONS
19 A. Timing of Challenges
20 1. Any party or Non-Party may challenge a designation of
21 confidentiality at any time that is consistent with the Court’s Scheduling
22 Order.
23 B. Meet and Confer
24
1 1. The Challenging Party shall initiate the dispute resolution process
2 under Local Rule 37.1 et seq.
3 C. The burden of persuasion in any such challenge proceeding shall be on
4 the Designating Party. Frivolous challenges, and those made for an improper
5 purpose (e.g., to harass or impose unnecessary expenses and burdens on other
6 parties) may expose the Challenging Party to sanctions. Unless the Designating
7 Party has waived or withdrawn the confidentiality designation, all parties shall
8 continue to afford the material in question the level of protection to which it is
9 entitled under the Producing Party’s designation until the Court rules on the
10 challenge.
11 VIII. ACCESS TO AND USE OF PROTECTED MATERIAL
12 A. Basic Principles
13 1. A Receiving Party may use Protected Material that is disclosed or
14 produced by another Party or by a Non-Party in connection with this
15 Action only for prosecuting, defending, or attempting to settle this Action.
16 Such Protected Material may be disclosed only to the categories of
17 persons and under the conditions described in this Order. When the
18 Action has been terminated, a Receiving Party must comply with the
19 provisions of Section XIV below.
20 2. Protected Material must be stored and maintained by a Receiving
21 Party at a location and in a secure manner that ensures that access is
22 limited to the persons authorized under this Order.
23 B. Disclosure of “CONFIDENTIAL” Information or Items
24
1 1. Unless otherwise ordered by the Court or permitted in writing by
2 the Designating Party, a Receiving Party may disclose any information or
3 item designated “CONFIDENTIAL” only to:
4 a. The Receiving Party’s Outside Counsel of Record in this
5 Action, as well as employees of said Outside Counsel of Record to
6 whom it is reasonably necessary to disclose the information for this
7 Action;
8 b. The officers, directors, and employees (including House
9 Counsel) of the Receiving Party to whom disclosure is reasonably
10 necessary for this Action;
11 c. Experts (as defined in this Order) of the Receiving Party to
12 whom disclosure is reasonably necessary for this Action and who
13 have signed the “Acknowledgment and Agreement to Be Bound”
14 (Exhibit A);
15 d. The Court and its personnel;
16 e. Court reporters and their staff;
17 f. Professional jury or trial consultants, mock jurors, and
18 Professional Vendors to whom disclosure is reasonably necessary
19 for this Action and who have signed the “Acknowledgment and
20 Agreement to be Bound” attached as Exhibit A hereto;
21 g. The author or recipient of a document containing the
22 information or a custodian or other person who otherwise
23 possessed or knew the information;
24
1 h. During their depositions, witnesses, and attorneys for
2 witnesses, in the Action to whom disclosure is reasonably
3 necessary provided: (i) the deposing party requests that the
4 witness sign the “Acknowledgment and Agreement to Be Bound;”
5 and (ii) they will not be permitted to keep any confidential
6 information unless they sign the “Acknowledgment and Agreement
7 to Be Bound,” unless otherwise agreed by the Designating Party or
8 ordered by the Court. Pages of transcribed deposition testimony or
9 exhibits to depositions that reveal Protected Material may be
10 separately bound by the court reporter and may not be disclosed to
11 anyone except as permitted under this Stipulated Protective Order;
12 i. Any mediator or settlement officer, and their supporting
13 personnel, mutually agreed upon by any of the parties engaged in
14 settlement discussions;
15 j. Nothing in Section VII (b) is intended to prevent officials or
16 employees of Defendants or other authorized governmental
17 officials from having access to the documents or other items if they
18 would have had access in the normal course of their job duties.
19 Further, nothing in this order prevents a witness from disclosing
20 events or activities personal to him or her, that is, a witness can
21 disclose to others information previously given to Defendants or its
22 employees with respect to what he or she saw, heard, or otherwise
23 sensed; and
24
1 k. Each person to whom disclosure of “confidential”
2 documents is made, with the exception of counsel, who are
3 presumed to know the contents of this Protective Order, shall be
4 provided by the person furnishing him/her such material a copy of
5 this order, and shall agree that he/she understands the provisions
6 of the Protective Order. Such person also must consent to be
7 subject to the jurisdiction of the presiding court with respect to any
8 proceeding relating to enforcement of this order, including without
9 limitation, any proceeding for contempt. Unless made on the
10 record in this litigation, counsel making the disclosure to any
11 person described above shall retain the original executed copy of
12 said agreement until final termination of this litigation.
13 IX. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED
14 IN OTHER LITIGATION
15 A. If a Party is served with a subpoena or a court order issued in other
16 litigation that compels disclosure of any information or items designated in this
17 Action as “CONFIDENTIAL,” that Party must:
18 1. Promptly notify in writing the Designating Party. Such notification
19 shall include a copy of the subpoena or court order;
20 2. Promptly notify in writing the party who caused the subpoena or
21 order to issue in the other litigation that some or all of the material
22 covered by the subpoena or order is subject to this Protective Order. Such
23 notification shall include a copy of this Stipulated Protective Order; and
24
1 3. Cooperate with respect to all reasonable procedures sought to be
2 pursued by the Designating Party whose Protected Material may be
3 affected.
4 B. If the Designating Party timely seeks a protective order, the Party served
5 with the subpoena or court order shall not produce any information designated
6 in this action as “CONFIDENTIAL” before a determination by the Court from
7 which the subpoena or order issued, unless the Party has obtained the
8 Designating Party’s permission. The Designating Party shall bear the burden
9 and expense of seeking protection in that court of its confidential material and
10 nothing in these provisions should be construed as authorizing or encouraging a
11 Receiving Party in this Action to disobey a lawful directive from another court.
12 X. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE
13 PRODUCED IN THIS LITIGATION
14 A. The terms of this Order are applicable to information produced by a Non-
15 Party in this Action and designated as “CONFIDENTIAL.” Such information
16 produced by Non-Parties in connection with this litigation is protected by the
17 remedies and relief provided by this Order. Nothing in these provisions should
18 be construed as prohibiting a Non-Party from seeking additional protections.
19 B. In the event that a Party is required, by a valid discovery request, to
20 produce a Non-Party’s confidential information in its possession, and the Party
21 is subject to an agreement with the Non-Party not to produce the Non-Party’s
22 confidential information, then the Party shall:
23
24
1 1. Promptly notify in writing the Requesting Party and the Non-Party
2 that some or all of the information requested is subject to a
3 confidentiality agreement with a Non-Party;
4 2. Promptly provide the Non-Party with a copy of the Stipulated
5 Protective Order in this Action, the relevant discovery request(s), and a
6 reasonably specific description of the information requested; and
7 3. Make the information requested available for inspection by the
8 Non-Party, if requested.
9 C. If the Non-Party fails to seek a protective order from this court within 14
10 days of receiving the notice and accompanying information, the Receiving Party
11 may produce the Non-Party’s confidential information responsive to the
12 discovery request. If the Non-Party timely seeks a protective order, the
13 Receiving Party shall not produce any information in its possession or control
14 that is subject to the confidentiality agreement with the Non-Party before a
15 determination by the court. Absent a court order to the contrary, the Non-Party
16 shall bear the burden and expense of seeking protection in this court of its
17 Protected Material.
18 XI. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL
19 A. If a Receiving Party learns that, by inadvertence or otherwise, it has
20 disclosed Protected Material to any person or in any circumstance not
21 authorized under this Stipulated Protective Order, the Receiving Party must
22 immediately (1) notify in writing the Designating Party of the unauthorized
23 disclosures, (2) use its best efforts to retrieve all unauthorized copies of the
24 Protected Material, (3) inform the person or persons to whom unauthorized
1 disclosures were made of all the terms of this Order, and (4) request such person
2 or persons to execute the “Acknowledgment and Agreement to be Bound” that is
3 attached hereto as Exhibit A.
4 XII. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE
5 PROTECTED MATERIAL
6 A. When a Producing Party gives notice to Receiving Parties that certain
7 inadvertently produced material is subject to a claim of privilege or other
8 protection, the obligations of the Receiving Parties are those set forth in Federal
9 Rule of Civil Procedure 26(b)(5)(B). This provision is not intended to modify
10 whatever procedure may be established in an e-discovery order that provides for
11 production without prior privilege review. Pursuant to Federal Rule of Evidence
12 502(d) and (e), insofar as the parties reach an agreement on the effect of
13 disclosure of a communication or information covered by the attorney-client
14 privilege or work product protection, the parties may incorporate their
15 agreement in the Stipulated Protective Order submitted to the Court.
16 XIII. MISCELLANEOUS
17 A. Right to Further Relief
18 1. Nothing in this Order abridges the right of any person to seek its
19 modification by the Court in the future.
20 B. Right to Assert Other Objections
21 1. By stipulating to the entry of this Protective Order, no Party waives
22 any right it otherwise would have to object to disclosing or producing any
23 information or item on any ground not addressed in this Stipulated
24 Protective Order. Similarly, no Party waives any right to object on any
1 ground to use in evidence of any of the material covered by this Protective
2 Order.
3 C. Filing Protected Material
4 1. A Party that seeks to file under seal any Protected Material must
5 comply with Civil Local Rule 79-5. Protected Material may only be filed
6 under seal pursuant to a court order authorizing the sealing of the specific
7 Protected Material at issue. If a Party's request to file Protected Material
8 under seal is denied by the Court, then the Receiving Party may file the
9 information in the public record unless otherwise instructed by the Court.
10 XIV. FINAL DISPOSITION
11 A. After the final disposition of this Action, as defined in Section V, within
12 sixty (60) days of a written request by the Designating Party, each Receiving
13 Party must return all Protected Material to the Producing Party or destroy such
14 material. As used in this subdivision, “all Protected Material” includes all copies,
15 abstracts, compilations, summaries, and any other format reproducing or
16 capturing any of the Protected Material. Whether the Protected Material is
17 returned or destroyed, the Receiving Party must submit a written certification to
18 the Producing Party (and, if not the same person or entity, to the Designating
19 Party) by the 60 day deadline that (1) identifies (by category, where appropriate)
20 all the Protected Material that was returned or destroyed and (2) affirms that the
21 Receiving Party has not retained any copies, abstracts, compilations, summaries
22 or any other format reproducing or capturing any of the Protected Material.
23 Notwithstanding this provision, Counsel are entitled to retain an archival copy of
24 all pleadings, motion papers, trial, deposition, and hearing transcripts, legal
1 memoranda, correspondence, deposition and trial exhibits, expert reports,
2 attorney work product, and consultant and expert work product, even if such
3 materials contain Protected Material. Any such archival copies that contain or
4 constitute Protected Material remain subject to this Protective Order as set forth
5 in Section V.
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1 B. Any violation of this Order may be punished by any and all appropriate
2 measures including, without limitation, contempt proceedings and/or monetary
3 sanctions.
4 IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD.
5
DATED: December 7, 2025 LYNBERG & WATKINS
6 A Professional Corporation
7
8 By: /s/ Garros Chan1
S. FRANK HARRELL
G. CRAIG SMITH
9
GARROS CHAN
Attorneys for Defendant
10 COUNTY OF ORANGE
11
DATED: December 8, 2025 POINTER & BUELNA, LLP
12 LAWYERS FOR THE PEOPLE
13
14 By: /s/Michael A. Slater
ADANTE POINTER
15 PATRICK BUELNA
MICHAEL A. SLATER
16 Attorneys for Plaintiff
ROMULO CORTEZ
17
FOR GOOD CAUSE SHOWN, IT IS SO ORDERED.
18
19 Dated: December 9, 2025 /s/ Autumn D. Spaeth
HONORABLE AUTUMN D. SPAETH
20 United States Magistrate Judge
21
22
23 1 Pursuant to California Central District Local Rule 5-4.3.4, all other signatories listed,
and on whose behalf the filing is submitted, concur in the filing’s content and have
24
authorized the filing.
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
5 have read in its entirety and understand the Stipulated Protective Order that was issue
6 by the United States District Court for the Central District of California on [DATE] in
7 the case of [insert formal name of the case and the
8 number and initials assigned to it by the Court]. I agree to comply with and to be
9 bound by all the terms of this Stipulated Protective Order and I understand and
10 acknowledge that failure to so comply could expose me to sanctions and punishment in
11 the nature of contempt. I solemnly promise that I will not disclose in any manner any
12 information or item that is subject to this Stipulated Protective Order to any person or
13 entity except in strict compliance with the provisions of this Order.
14 I further agree to submit to the jurisdiction of the United States District Court
15 for the Central District of California for the purpose of enforcing the terms of this
16 Stipulated Protective Order, even if such enforcement proceedings occur after
17 termination of this action. I hereby appoint [print or
18 type full name] of [print or type full address and
19 telephone number] as my California agent for service of process in connection with this
20 action or any proceedings related to enforcement of this Stipulated Protective Order.
21 Date:
22 City and State where sworn and signed:
23 Printed Name:
24 Signature: