Placer — Proposed Statement on Appeal (Infraction)

Source: https://www.placer.courts.ca.gov/sites/default/files/pl-ap003.pdf

SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER

ATTORNEY OR UNREPRESENTED PARTY FOR COURT USE ONLY (Name, State Bar number, and Address):

TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: SUPERIOR COURT OF CALIFORNIA, COUNTY OF PLACER 10820 Justice Center Drive P.O. Box 619072 Roseville, CA 95661-9072 APPELLANT:

RESPONDENT: PROPOSED STATEMENT ON APPEAL (INFRACTION) CASE NUMBER:

I, , submit this proposed statement on appeal pursuant to California Rules of Court, Rule 8.916 and declare as follows:

Trial in this matter was held on .

The following is a brief description of what occurred at the trial:

Number of additional pages attached:

I declare under the penalty of perjury of the laws of the State of California that the foregoing is true and correct.

DATE:

PRINTED NAME SIGNATURE

Form Adopted for Optional Use California Rules of Court, Rules 8.916 Superior Court of California, County of Placer www.placer.courts.ca.gov Local Form PL-AP003 Effective 08-03-2015