Riverside local form RI-PR107

Source: https://www.riverside.courts.ca.gov/system/files/2023-10/RI-PR107.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE

INDIO 46-200 Oasis St., Indio, CA 92201 RIVERSIDE 4050 Main St., Riverside, CA 92501
MURRIETA 30755-D Auld Rd., Murrieta, CA 92563
RI-PR107

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

IN THE MATTER OF:

CASE NUMBER:

APPOINTMENT, TERMINATION, OR RESIGNATION OF SUPPORTER

Note: The Respondent may use this form to appoint a Supporter with access to the court’s file in this case, or terminate the authority of the Supporter. The Supporter may also use this form to resign.

1. Respondent’s name is: .

2. This document concerns the following individual: a. Name: Telephone: b. Address: c. Email:

3. Respondent: a. Appointment: I appoint the person at item 2 as my Supporter.

   b. Health Records and Court File (1) Granted: As my supporter, the person at item 2 can receive documents and information with protected health information and mental health records (excluding psychotherapy notes) from the county behavioral health agency and can inspect the court’s file in the CARE Act proceeding. (2) Denied: The person at item 2 cannot receive documents and information with protected health information and mental health records from the county behavioral health agency, or inspect the court’s file in the CARE Act proceeding.

   c. Termination: The person at item 2 is no longer my supporter.

4. The person at item 2 hereby resigns as Supporter.

   Dated: (SIGNATURE OF SUPPORTER)

Dated:

(TYPE OR PRINT NAME OF RESPONDENT’S ATTORNEY) (SIGNATURE OF RESPONDENT’S ATTORNEY)

(TYPE OR PRINT NAME OF RESPONDENT) (SIGNATURE OF RESPONDENT)

Approved for Optional Use APPOINTMENT, TERMINATION OR riverside.courts.ca.gov Riverside Superior Court Form RI-PR107 [Rev. 03/13/24] RESIGNATION OF SUPPORTER (Reformatted 12/23/24)