Santa Clara — CV-5058*

Source: https://santaclara.courts.ca.gov/system/files/forms/cv-5058_rem.pdf

ATTACHMENT CV-5058 ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS) TELEPHONE NUMBER: FOR COURT USE ONLY

ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS:

MAILING ADDRESS: 191 North First Street

CITY AND ZIP CODE: San José, California 95113

BRANCH NAME:

PETITIONER:

RESPONDENT:

OTHER PARTY:
STIPULATION AND ORDER CASE NUMBER:
Modification DEPARTMENT:

1. Not based on a hearing

   Today’s Hearing (date)

2. Judge:

3. Parties/Attorneys:

   Petitioner present in court Petitioner’s attorney present:

   Respondent present in court Respondent’s attorney present:

   Other party present in court Other party’s attorney present:

   Do not use this form for Civil Harassment Restraining Order after Hearing.
   Those orders must be made on form CH-130.
   In addition, do not use this form for Continuance and Reissuance.
   Those orders must be made on form CH-116.

4. The parties agree that the Court will make orders about the following items:

   OtherOtherOther orders:orders:orders: SeeSee AttachmentAttachment Not Applicable

   Attorney’sAttorney’s feesfees andand costs:costs: SeeSee AttachmentAttachment Not Applicable

   Petitioner

   Respondent

CV-5058 REV 02/10/12 STIPULATION AND ORDER Page 1 of 2

ATTACHMENT CV-5058 PETITIONER: CASE NUMBER:

RESPONDENT:

We have read this entire Stipulation and Order, including all Attachments. We understand it fully and ask that the Court make our stipulation the Court’s orders. We give up the right to all further notice of this order.

Date: Petitioner

Date: Attorney for Petitioner

Date: Respondent

Date: Attorney for Respondent

Date: Other party:

Date: Attorney for Other party:

Interpreter Witness Declaration

Interpreter: The Petitioner Respondent Other party is unable to read or understand this
Stipulation and Order and its attachments because:

a. his/her primary language is (specify):
b. other (specify):

I certify under penalty of perjury under the laws of the State of California that I have, to the best of my ability, read or translated for the Petitioner Respondent Other party this Stipulation and Order including all attachments. He or she said they understood this Stipulation and Order and its attachments before signing them.

Date Interpreter’sInterpreter’sInterpreter’sInterpreter’s printedprintedprintedprinted namenamenamename Interpreter’s signature

ORDER

The Court approves the terms stipulated and agreed to by the parties in this document and makes them court orders.

Date: Judicial Officer of the Superior Court

Petitioner

Respondent

CV-5058 REV 02/10/12 STIPULATION AND ORDER Page 2 of 2