Orange — Appealing a Civil Citation

Source: https://www.occourts.org/system/files/selfhelp/shc-app-04.pdf

SUPERIOR COURT SUPERIOR COURT OF OF CALIFORNIA CALIFORNIA Self-Help Services Self-Help Services COUNTY OF COUNTY ORANGE OF ORANGE www.occourts.org/self-help www.occourts.org/self-help APPEALINGAA CIVIL APPEALING CIVIL CITATION CITATION SELF-HELP FORM SELF-HELP FORM PACKET PACKET SHC-APP-04 (Rev. SHC-APP-04 (Rev. 7/01/2026) 7/01/2026) www.occourts.org/self-help www.occourts.org/self-help

ATTORNEY ATTORNEY OR NAME: NAME: FIRM NAME: FIRM STREET ADDRESS: STREET cry: CITY: [TELEPHONE TELEPHONE NO. EMAIL ADDRESS: EMAIL ATTORNEY ATTORNEY FOR SUPERIOR SUPERIOR COURT STREET ADDRESS: STREET MAILING ADDRESS: MAILING ICITY CITY AND CASE NAME: CASE (J) 1. Rev. Cal, Cal. NAME: OR PARTY ADDRESS: NO.: ADDRESS: FOR (name): COURT OF ADDRESS: ADDRESS: ZIP CODE: AND ZIP BRANCH BRANCH NAME: NAME: CIVIL CASE COVER SHEET Unlimited (Amount (Amount demanded demanded exceeds (1. Check one box Auto Auto Tort pon Tort Asbestos PARTY WITHOUT WITHOUT ATTORNEY (name): Auto CALIFORNIA, COUNTY OF CALIFORNIA, CODE: NAME: exceeds $35,000) $35,000) box below below for Auto (22) (22) Uninsured motorist Asbestos Asbestos (04) other PUPDIWD (P Other PI/PD/WD ‘ Damage/Wrongful “Judicial Product Non-PI/PD/WD Rev. July Cal. Rules Cal. Stds. ' Other Business ou rights Civil patente Defamation Other Employment Employment Wrongful Other judicial Counc Council of 1, 2026, July 1, of Court, Rules of Stds. Jud. Limited Limited Fraud (16) ATTORNEY COUNTY OF Items Items 1–6 for the 1-6 below the case case type (46) motorist (46) (04) ersonal Tort (Personal Death) Damage/Wrongful Death) Tort a (24) Product liability liability (24) (23) , Medical malpractice (45) Medical malpractice (45) Other PI/PD/WD PI/PD/WD (23) (Other) Tort Non-PI/PD/WD (Other) Tort tort/Unfair business Business tort/Unfair Civil rights (08) rig “ (08) }efamation (13) raud (16) Intellectual Professional Other non-PI/PD/WD employment (15) Other employment of Califia, 2026, Mandatory Court, rules Admin., std. Jud. Admin,, (i Wrongful termination ) business practice property (19) Intellectual property non-PI/PD/WD tort termination (36) (36) (15) California, courts.ca.g0v rules 2.30, (19) negligence (25) Professional negligence tort (35) Mandatory Form courts.ca.gov Form 2.30, 3.220, std. 3.10 3.10 OF type that be completed must be below must (25) (35) (Amount (Amount demanded demanded is $35,000 $35,000 or that best is or less) less) (see instructions completed (see best describes Injury/Property (07) 3.400–3.403, 3.740 3.220, 3.400-3.403, 3.740 7 case: this case: describes this 1 injurylProperty Injury/Prope! practice (07) Real FAX ; STATE STATE BAR STATE: STATE: FAX NO. Complex Case Counter Counter Filed with first appearance by defendant (Cal. (Cal. instructions on Contract Contract Breach of Other Insurance Eminent EDD NO.: . Rules on page Breach Rule 3.740 Rule Property Real Property Wrongful Other real Other Unlawful BAR NUMBER: NUMBER: Case Designation Detainer Unlawful Detainer of Court, rule 3.402) of page 2 ZIP CODE: ZIP Designation Court, and examples 2 and contractwarranty (06) of contract/warranty Song-Beverly Act: Song-Beverly Lemon Law (49) Lemon Law (49) Act: Motor 3.740 collections collections (09) collections (09) Other collections Insurance coverage coverage (18) ther contract (37) Other contract (37) Eminent domain/inverse domain/Inverse condemnation (14) condemnation (14) Wrongful eviction eviction (33) property (26) real property Commercial (31) Commercial Residential (32) Residential (32) Drugs (38) Drugs Judicial (38) Review Judicial Review (31) Joinder examples on Motor Vehicle (33) Asset forfeiture (05) Asset forfeiture (05) Petition re Petition CODE: rule ss) Vehicle (09) (26) re arbitration arbitration award Antor mandts (02) Joinder (09) Writ of mandate (02) award (11) Other judicial review (39) Other judicial review (39) Employment Department Civil Development Employment Development Department (EDD) (EDD) EDD decision decision review Civil Case review (48) Case Cover (48) Cover Sheet Sheet 3.402) (06) (11) CASE CASE NUMBER: defendant | /U°S& on page page 3). 3). JUDGE: DEPT. DEPT.: Provisionally Complex Provisionally (Cal. Antitrust/Trade regulation Mass tort : of Court, (Cal. Rules of Antitrust/Trade above (41) NUMBER: Construction Construction defect Insurance (41) Enforcement of Enforcement Miscellaneous Complex Civil RICO (27) RICO (27) Other Miscellaneous Partnership [1 Other Court, rules 3.400-3.404) defect (10) (40) tort (40) ‘Securities Comprehensive above listed Enforcement of Enforcement Miscellaneous Civil Miscellaneous Civil Partnership and Other petition

Judgment FOR COURT Civil Litigation regulation (03) Insurance coverage of judgment Complaint Civil Complaint complaint (not Other complaint FOR (10) litigation (28) Securities litigation Environmental/Toxic tort Environmental/Toxic of Judgment Civil Petition Petition petition (not Other petition COURT USE USE ONLY Litigation ONLY 3.400–3.404) (03) (28) : tort (30) Comprehensive groundwater groundwater adjudication coverage claims claims arising listed provisionally provisionally complex (20) judgment (20) (not (30) adjudication (47) (42) from the arising from complex case above) (42) specified above) (not specified and corporate corporate governance (not specified case types governance (21) spectied above) specified above) (47) types (43) above) (43) CM-010 the (43) CM-010,, Page CM-010 (21) Page 11 of of 33

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Date: Date: © @ e ¢ check item of may To from To case the If the b. c. c. d. e. f. this case Is this Rev. a. a. b. d. e. f. a. a. b. b. c. c. the case Number of 4. Number complex under case complex is complex, case is Large Large number Extensive Substantial Large Large number Coordination Substantial monetary monetary nonmonetary; punitive punitive of causes of Plaintiff must Plaintiff Code, Family C Unless Family C File this cover File IfIf this complete cover sheet this ccase is this cover this Unl check one item o1, m cover sheet o To Plaintiffs and Others Filing and file, complete and box for one box file, along compile statistics about the omore 1, check the action. To assist action. this form. of this may subject To Parties action for recovery of arising from aa transaction arising from seeking form. A subject Parties in seeking the prejudgment prejudgment writ the general from the 3.740 collections case will To Parties complaint a a party, the following: Parties in is complex. case is d completing complaint on plaintiff's plaintiffs designation, case is the case July 1, Rev. July 1, for the A cover number of number of file this sheet sheet in is c the case assist you in cover sheet party, Rule 3.740 in Rule following: (1) writ of in Complex d the appropriate all parties on all file o its designation, a is scomplex. complex. 2026 2026 m ortheseq.oforthetheactionCourCto,uorft,Cou3r.t2,0.)3.20.)ortheof sothermal3.740, under rule rule 3.400 mark the complex, mark Extensive motion separately represented Coordination with of the 3.400 of factors requiring the factors of separately practice raising motion practice Substantial amount amount of documentary evidence of documentary of witnesses witnesses with related Substantial postjudgment postjudgment judicial sought (check all that related actions judicial supervision apply): that apply): of action (specify): (specify): Is this case a class action suit? suit? 6. If there are any known related cases, or print Type or this cover Code, or Welfare Welfare a in addition to complex un on all sheet under this is a collections c ss this is a collections case n along with with your case type more specific one. sheet must its counsel, u must be counsel, or represented parties raising difficult actions pending or injunctive relief nonmonetary; declaratory or cases, file file and serve a notice of print name cover sheet with with the first and Institutions to any cover rule 3.400 er rule all other parties parties to er rule under Filing First First Papers. first paper, your first about the types and numbers type that that best one. IfIf the in completing the sheet, filed only be filed or both to sanctions under 3.740 Collections Collections Cases. of money aowed in transaction in in which (1) tort of attachment. general time-for-service Complex Cases. Cases. In complex. IfIf aa plaintiff believes parties to boxes in to the s California Rules the California evidence cover sheet 3.400 et tort damages, will be subject the case only with in a sum time-for-service requirements subject to In complex the action. 3.740 or a rule 3.740 paper, the numbers of which property, damages, (2) the case believes the counter-designation that a counter-designation (proceeding.case,except of Court? Rules of requiring exceptional exceptional judicial parties difficult or or novel in one pending in supervision Yes first pap one or Yes paper Court? judicial management: issues that novel issues or more more courts of related case. filed in er filed Institutions Code). Code). (Cal. courts in (Cal. Ru sheet required by local complex cases No No management: case. (You may Rules local court et seq. of the California to the action California Ru action or proceeding. (Cal. ac best describes case has that will complex case, this INSTRUCTIONS ON HOW Papers. IfIf you are filing sheet, examples with your Cases. A Civil Case the Civil the case. describes the Case Cover of cases filed. has multiple examples of your initial A "collections services, or property, services, (2) punitive punitive damages, attachment. The identification of requirements and case is in items 11 and 2. action. AA defendant and case cases only, is complex under defendant maymay file case is the case that the Civil Case Civil will be in other Rules case. IfIf the multiple causes initial paper. "collections case" sum stated to be certain that or money damages, (3) case management only, parties file and Case Cover be time-consuming other counties, may use form in the action or or proceeding of Court, rule les of court rule. rule. of Court, or les of (Cal. R this cover Rules filing a first paper Cover Sheet Sheet contained filed. You must causes of ul of Court, rule cover sheet will case fits the case of the cases that of action, Failure to paper. Failure under rules 2.30 and 3.220 of case" under that is was acquired money was (3) recovery management rules, must also parties must is not or will b contained on fits both that belong under to file under rule is not acquired on recovery of also use rule 3.400 under rule serve no and serve Cover Sheet Sheet be u 3.400 of no later complex, or, not complex, sheet both a use the Yes Yes to resolve time-consuming to counties, states, states, or proceeding (except small claims c aa collections paper (for example, example, a complaint) rule 3.740 of real or countries, countries, or Failure to collections c used for resolve CM-015.) form CM-015.) rule 3.220.) Failure rule 3.220.) for statistical action, check the rules, unless statistical purposes only. on pages pages 11 and must complete items 11 through 6 on the sheet. general and a general the box cover sheet file aa cover of the California 3.740 ofof the not more than $35,000, on credit. credit. A property, (4) real property, of a case as a rule 3.740 collections case on this form unless aa defendant to the requirements for service and obt

n, check the rules, unless statistical purposes only. on pages pages 11 and must complete items 11 through 6 on the sheet. general and a general the box cover sheet file aa cover of the California 3.740 ofof the not more than $35,000, on credit. credit. A property, (4) real property, of a case as a rule 3.740 collections case on this form unless aa defendant to the requirements for service and obtaining a judgment the Civil of the than the complaint) in box that 2. IfIf a plaintiff designates a case as complex, later than or, if the claims to file file may case un or in of party or Signature of may result er rule under and 2. and a sheet with a s judgment in Civil Case the California the time time of e s in a cases or cases result in rule 3.740, y 2. This more more a a under each case type in No No a federal in a civil This information indicates the best indicates that best the first with the Rules of California Rules the California $35,000, exclusiveu of collections case A collections (4) recovery defendant files Case Cover recovery of in rule 3.740. Cover Sheet California Rules of complex, the cover of its federal court or attorney for party only. its first e c in sanctions. you m civil case, specific specific type in item sheet. In a sanctions. court must serve a copy of information will paper filed first paper of Court. Court. Rules of filed filed un case, you must the primary item 1 are provided on page 3 of Court of interest interest and attorney's fees, case does r under type of primary cause filed in Court is of personal form means Sheet to In item not include does not personal property, means that files aa responsive responsive pleading. 3.740. ofs Court, to designate Court, s designate whether this this must sheet must cover sheet first appearance the plaintiff has made no designation, SEE PAGE 3 FOR INFORMATION PURPOSES ONLY. e er the Probat serve will be item 1, of case case listed in a is defined include an property, or that it will pleading. A must be appearanceaa joinder designation, a Probate must used to be used must 1, you must in listed in cause ofof civil case a civil o joinder in case defined asas an an action will be exempt A rule be indicated action or (5) exempt rule whether the indicated by must be served with the in the the a designation designation that CM-010,, Page CM-010 Page p to an fees, (5) a the by ONLY. 22 of of33

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CM-010 CASE TYPES CASE TYPES AND AND EXAMPLES EXAMPLES The list below The list below provides provides explanations explanations and and examples examples for for the the case case type type checkboxes checkboxes listed listed in in item item 11 on on this this form. form. The The lists of examples lists of examples below are below are not meant to not meant to be be exhaustive, exhaustive, and and some some case case types types may have causes may have causes of action not of action listed here. not listed here. Auto Auto Tort Tort Contract Contract Provisionally Complex Provisionally Complex Civil Civil Litigation Litigation (Cal. (Cal. ‘Auto Auto (22)-Personal (22)–Personal Injury/Property Damage/ Injury/Property Damage/ Breach of Breach of ContractWarranty Contract/Warranty (06) (06) Rules of Rules of Court, rules 3.400-3.404) Court, rules 3.400–3.404) Wrongful Wrongful Death Death Breach Breach of of Rental/Lease Rental/Lease Contract (not Contract (not Antitrust/Trade Regulation Antitrust/Trade (03) Regulation (03) Uninsured Motorist Uninsured (if the Motorist (if case involves the case involves an an unlawful detainer or unlawful detainer or wrongful wrongful eviction) eviction) Construction Defect Construction Defect (10) (10) uninsured motorist uninsured motorist claim claim subject subject to to ContractWarranty Breach–Seller Contract/Warranty Breach-Seller Plaintiff Plaintiff Mass Tort Mass Tort (40) (40) arbitration, check this arbitration, check this item instead of item instead of Auto) Auto) (not fraud) (not fraud) Securities Litigation Securities (28) Litigation (28) (46) (46) Negligent Breach Negligent Breach of of ContractWarranty Contract/Warranty Environmental/Toxic Tort Environmental/Toxic Tort (30) (30) Other Breach Other Breach of of ContractWarranty Contract/Warranty Comprehensive Groundwater Comprehensive Groundwater Adjudication Adjudication Asbestos Asbestos ‘Song-Beverly Song-Beverly Act: Act: Motor Motor Vehicle Vehicle Lemon Lemon Law Law (47) (47) Asbestos Asbestos (04) (04) (check this (check this item item ifif the the case case involves involves aa Song- Song- Insurance Coverage Insurance Coverage Claims Claims (arising (arising from from ‘Asbestos Asbestos Property Property Damage Damage Beverly Act Beverly Act claim regarding aa motor claim regarding motor provisionally complex case provisionally complex case type listed type listed Asbestos Asbestos Personal Personal Injury/Wrongful Injury/Wrongful DeathDeath vehicle) (49) vehicle) (49) above) (41) above) (41) Other PI/PD/WD Other PI/PD/WD (Personal Injury/ (Personal Injury/ Rule 3.740 Collections Rule 3.740 Collections (as (as defined defined inin Cal. Cal. Enforcement of of Judgment Property Damage/Wrongful Property Damage/Wrongful Death) Death) Tort Tort Rules Rules of of Court, Court, rule rule 3.740(a)) (09) 3.740(a)) (09) Enforcement Enforcement Judgment of Judgment (20)(20) Product Liability Product (not asbestos Liability (not asbestos or or Other Collections Other Collections (e.g., (e.g., money money owed, owed, open open Enforcement of Abstract of Judgment Judgment Judgment (Out of County) environmentaltoxic tort) (24) book accounts, book promissory note) accounts, promissory note) (09) (09) Abstract of (Out of County) environmental/toxic tort) (24) Insurance Coverage Insurance (not provisionally Confession of Confession Judgment of Judgment (non-domestic (non-domestic Medical Malpractice Medical Malpractice (45) (45) Coverage (not provisionally relations) Medical Malpractice-Physicians && complex) (18) complex) (18) relations) Medical Malpractice–Physicians ‘Auto Auto Subrogation Sister-State Judgment Sister-State Judgment Surgeons Surgeons Subrogation Administrative Administrative Agency Agency Award Other Professional Other Professional HealthHealth Care Care Other Coverage Other Coverage Petition/Certification of Award Entry of of Judgment Malpractice Other Contract Other Contract (37) (37) Petition/Certification of Entry Judgment Malpractice Other PI/PD/WD PI/PD/WD (23) Contractual Fraud Contractual Fraud on on Unpaid Taxes Unpaid Taxes Other Premises Liability Premises (23) Liability (e.g., (e.g., slip slip and and fall) fall) Other Contract Other Dispute Contract Dispute Other Enforcement Other Enforcement of of Judgment Judgment Case Case Intentional Bodily Injury/PD/WD Intentional Bodily Injury/PD/WD (e.g ... (e.g., Real Property Real Property Miscellaneous Civil Miscellaneous Civil Complaint Complaint assault, assault, vandalism) vandalism) Eminent Eminent Domain/Inverse Condemnation Domain/Inverse Condemnation (14) (14) RICO (27) RICO (27) Intentional Infliction Intentional Infliction of of Emotional Emotional Distress Distress Wrongful Eviction Wrongful Eviction (33) (33) Other Complaint Other Complaint (not (not specified specified above) above) (42) (42) Negligent Infliction Negligent Infliction of of Emotional Emotional Distress Distress Other Real Other Property Real Property (e.g., quiet (e.g., quiet title) title) (26) (26) Declaratory Declaratory Relief Relief Only Only Other P/PD/WD Other PI/PD/WD Writ of Writ of Possession Possession of of Real Real Property Property Injunctive Relief Only Injunctive Relief Only (non-harassment) (non-harassment) Non-PI/PD/WD (Other) Tort Mortgage Foreclosure Mortgage Foreclosure Mechanic's Mechanic's Lien Lien Non-PI/PD/WD Business (Other) Tort Tort/Unfair Business Business Tort/Unfair Practice (07) Business Practice (07) Quiet Title Quiet Title Other Commercial Other Commercial Complaint Complaint Case Case Other Real Property (not unlawful (non-tort/non-complex) (non-tort/non-complex) Civil Rights Civil Rights (e.g., (e.g., discrimination, discrimination, false false arrest) arrest) Other Real Property (not unlawful Other Civil Civil Complaint (non-tort/ (not civil (not civil harassment) harassment) (08) (08) detainer) detainer) Other Complaint (non-tort/ non-complex) non-complex) Defamation (e.g., Defamation (e.g., slander, libel) (1

on-tort/non-complex) (non-tort/non-complex) Civil Rights Civil Rights (e.g., (e.g., discrimination, discrimination, false false arrest) arrest) Other Real Property (not unlawful Other Civil Civil Complaint (non-tort/ (not civil (not civil harassment) harassment) (08) (08) detainer) detainer) Other Complaint (non-tort/ non-complex) non-complex) Defamation (e.g., Defamation (e.g., slander, libel) (13) slander, libel) (13) Unlawful Detainer Unlawful Detainer Fraud (other than Fraud (other than contract) contract) (16) (16) Commercial (31) Commercial (31) Miscellaneous Civil Miscellaneous Civil Petition Petition Intellectual Property (19) Intellectual Property (19) Residential (32) Residential (32) Partnership Partnership and and Corporate Corporate Governance (21) Governance (21) Professional Negligence (25) Professional Negligence (25) Drugs Drugs (if (if the case the case involves involves illegal illegal drugs, check drugs, check Other Petition Other (not specified Petition (not specified above) (43) above) (43) Legal Malpractice Legal this item; Civil Harassment Civil Malpractice Other Professional Professional Malpractice this item; otherwise, otherwise, choose Commercial or choose Commercial or Harassment Workplace Violence Other Malpractice Residential) (38) Residential) (38) Workplace Violence (not medical) (not medical) Elder/Dependent Adult Elder/Dependent Adult Abuse Abuse Other Non-PI/PD/WD Other Non-PI/PD/WD Tort Tort (35) (35) Judicial Review Judicial Review Election Contest Election Contest Asset Forfeiture Asset Forfeiture (05) (05) Petition Petition forfor Name Change Name Change Employment Employment Petition Petition re re Arbitration Arbitration Award Award (11) (11) Petition Petition forfor Relief Relief From Government From Government Wrongful Termination Wrongful Termination (36) Claim Requirement Other Employment Employment (15) (36) Writ of Writ of Mandate (02) Mandate (02) Claim Requirement Other (15) Writ–Administrative Mandamus Writ-Administrative Mandamus Other Civil Other Civil Petition Petition Writ–Mandamus on Writ-Mandamus on Limited Limited Court Case Court Case Matter Matter Writ-Other Limited Writ–Other Court Case Limited Court Review Case Review Other Judicial Other Judicial Review Review (39)(39) Review Review of of Health Officer Order Health Officer Order Notice Notice of of Appeal-Labor Appeal–Labor Commissioner Commissioner Appeals Appeals Employment Development Employment Development Department Department (EDD) (EDD) EDD Decision EDD Review (if Decision Review (if the the case case involves involves an an Employment Development Department Employment Development Department decision, check this decision, check this item instead of item instead of wrongful termination wrongful termination or or other other employment) employment) (48) (48) Rev. July Rev. 1, 2026 CM-010,, Page Page 33 of of 33 July 1, 2026 Civil Case Cover Civil Cover Sheet Sheet CM-010

ATTORNEY OR ATTORNEY OR PARTY WITHOUT ATTORNEY PARTY WITHOUT ATTORNEY (Name (Name & Address): & Address): FOR COURTUSE FOR COURT USE ONLY ONLY Telephone No.: Telephone No.: Fax No. Fax No. (Optional) (Optional): E-Mail Address E-Mail Address (Optional): (Optional): ATTORNEY ATTORNEY FORFOR (Name): (Name): Bar No: Bar No: SUPERIOR COURT SUPERIOR COURT OF OF CALIFORNIA, CALIFORNIA, COUNTY COUNTY OF OF ORANGE ORANGE EGPVTCN'JUSTICE CENTER: JUSTICE CENTER: 700 Civic Center 700 Civic Center Dr. Dr. West, West, Santa Santa Ana, CA 92701-4045 Ana, CA 92701-4045 APPELLANT: "APPELLANT: RESPONDENT: RESPONDENT: NOTICE OF APPEAL NOTICE OF APPEAL - – CIVIL CIVIL CITATION CITATION NO: CASE NO: Civil Citation Civil Citation fine/penalty fine/penalty UO has † been paid. has been paid. has been Chas † been waived waived by the citing by the citing agency. agency. Contestant/Appellant, Contestant/Appellant, ,, of the above of the above entitled entitled action, action, having exhausted having exhausted the the administrative administrative review process, hereby review process, appeals to hereby appeals the Superior to the Superior Court Court of California, County of California, County of Orange of Orange from the from the final final decision decision of the administrative of the administrative review, review, which which was was mailed or personally mailed or served on personally served on —_______E—”, regarding Civil regarding Civil Citation Citation number: number: . I| declare under penalty declare under penalty of of perjury perjury under the laws under the laws of the State of the State of of California that the California that the foregoing foregoing is is true true and and correct. correct. Date: Date: ((TYPE TYPE OR OR PRINT PRINT NAME) NAME) (SIGNATURE OF (SIGNATURE OF APPELLANT APPELLANT OR ATTORNEY) OR ATTORNEY) NOTE: A NOTE: A separate separate appeal appeal must be filed must be filed for for each each civil civil citation. citation. AA copy copy of this document of this document must be mailed must be mailed to the citing to the citing agency. The agency. The original original appeal appeal with with proof proof of service must of service must be filed with be filed with the the court court with with the the proper filing fee. proper filing fee. PROOF OF PROOF OF SERVICE SERVICE BY BY MAIL MAIL

|I deposited

deposited a a copy copy of the Notice of the Notice of Appe al of Appe al in in the the United United St mail, in States mail, in aa sealed sealed envelope envelope with with postage fully prepaid. postage fully prepaid. The The envelope was envelope was addressed addressed as as follows: follows: (Name and address (Name and address of citing agency) of citing agency) Date of Date mailing: of mailing: Place Place of mailing (city of mailing (city and and state): state): . am a I| am a resi dent of resident or empl of or in the employed in the county county whe whe re the Notice re the Notice of of Appeal was mailed. Appeal was mailed. My address business address or business residence or My residence is: Street is: Street Address: Address: City: City: State: State: .: I| declare under penalty declare under penalty of of perjury perjury under the laws under the laws of the State of the State of of California that the California that the foregoing foregoing is is true true and and correct. correct. Date: Date:

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(TYPE OR (TYPE PRINT NAME) OR PRINT NAME) (SIGNATURE OF (SIGNATURE OF DECLARANT) DECLARANT) Approved for Approved for Optional Use Optional Use NOTICE OF NOTICE OF APPEAL APPEAL-- CIVIL CIVIL CITATION CITATION Govt. Code Govt. § 53069.4 Code § 53069.4 L-1044 (Rev. L-1044 (Rev. July July 2013) 2013) www.occourts.org www.occourts.org