Gabriel Hernandez v. City of Ontario and Does 1-10, Inclusive

Opinion

1 JONES MAYER James R. Touchstone, State Bar No. 184584 2 jrt@jones-mayer.com Thurgood M. Wynn, State Bar No. 345199 3 tmw@jones-mayer.com 3777 North Harbor Boulevard 4 Fullerton, California 92835 Telephone: (714) 446-1400 5 Facsimile: (714) 446-1448

6 Attorneys for Defendant CITY OF ONTARIO 7

8 UNITED STATES DISTRICT COURT

9 CENTRAL DISTRICT OF CALIFORNIA

11 GABRIEL HERNANDEZ, Case No.: 5:26-cv-00455-DTB

12 Plaintiff, Assigned for all Purposes to: Hon. Magistrate Judge David T. Bristow 13 vs. Courtroom 4

14 CITY OF ONTARIO and DOES 1-10, STIPULATED PROTECTIVE ORDER Inclusive, 15 Defendants. Action Filed: February 2, 2026 16 17 18 1. A. PURPOSES AND LIMITATIONS 19 Discovery in this action is likely to involve production of confidential, 20 proprietary, or private information for which special protection from public 21 disclosure and from use for any purpose other than prosecuting this litigation may 22 be warranted. Accordingly, the parties hereby stipulate to and petition the Court to 23 enter the following Stipulated Protective Order. The parties acknowledge that this 24 Order does not confer blanket protections on all disclosures or responses to 25 discovery and that the protection it affords from public disclosure and use extends 26 only to the limited information or items that are entitled to confidential treatment 27 under the applicable legal principles. The parties further acknowledge, as set forth 28 in Section 12.3, below, that this Stipulated Protective Order does not entitle them 1 to file confidential information under seal; Civil Local Rule 79-5 sets forth the 2 procedures that must be followed and the standards that will be applied when a 3 party seeks permission from the court to file material under seal. 4 B. GOOD CAUSE STATEMENT 5 One or more of the Parties represent that pre-trial discovery in this case 6 may include matters that are confidential and privileged and may require the 7 discovery of and/or production of documents pertaining to the City of Ontario 8 Police Department’s investigation of the underlying criminal activities, as well as 9 peace officer personnel file information and/or documents which the Parties agree 10 which may include: (1) Personal data; (2) Medical history; (3) Election of 11 employee benefits; (4) Employee advancement, appraisal, or discipline; and (5) 12 Complaints, or investigations of complaints, if any, concerning an event or 13 transaction in which a peace officer may have participated, or which a peace 14 officer may have perceived, and may pertaining to the manner in which the peace 15 officer performed his or her duties. Without waiving objections to the production 16 of such documentation and information, such confidential materials and 17 information consist of, among other things, materials entitled to privileges and/or 18 protections under the following: United States Constitution, First Amendment; the 19 California Constitution, Article I, Section 1; California Penal Code §§ 832.5, 20 832.7 and 832.8; California Evidence Code §§ 1040 and 1043 et. seq; the Privacy 21 Act of 1974, 5 U.S.C. § 552; Health Insurance Portability and Accountability Act 22 of 1996 (HIPAA); the right to privacy; decisional law relating to such provisions; 23 and information otherwise protected from disclosure under state or federal 24 statutes, court rules, case decisions, or common law. Defendants also contend that 25 such confidential materials and information is entitled to the Official Information 26 Privilege. Sanchez v. City of Santa Ana, 936 F.2d 1027, 1033 (9th Cir. Cal. 1990); 27 see also Kerr v. United States Dist. Ct. for N.D. Cal., 511 F.2d 192, 198 (9th 28 Cir.1975), aff'd, 426 U.S. 394, 96 S.Ct. 2119, 48 L.Ed.2d 725 (1976). Further, 1 discovery may require depositions, written discovery and/or the production of 2 certain City of Ontario Police Department policies and procedures and peace 3 officer training information the public disclosure of which may could comprise 4 officer safety, and/or raise security issues. Defendants contend that public 5 disclosure of such material and information poses a substantial risk of 6 embarrassment, oppression and/or physical harm to peace officers whose 7 confidential information is disclosed. Defendants further contend that this 8 potential risk of harm to peace officers is greater than with other government 9 employees due to the nature of their profession. Finally, Defendants contend that 10 the benefit of public disclosure of confidential information is minimal while the 11 potential disadvantages may be great. 12 Accordingly, to expedite the flow of information, to facilitate the prompt 13 resolution of disputes over confidentiality of discovery materials, to adequately 14 protect information the parties are entitled to keep confidential, to ensure that the 15 parties are permitted reasonable necessary uses of such material in preparation for 16 and in the conduct of trial, to address their handling at the end of the litigation, and 17 serve the ends of justice, a protective order for such information is justified in this 18 matter. It is the intent of the parties that information will not be designated as 19 confidential for tactical reasons and that nothing be so without a good faith belief 20 that it has been maintained in a confidential, non-public manner, and there is good 21 cause why it should not be part of the public record of this case. 22 2. DEFINITIONS 23 2.1 Action: Gabriel Hernandez v. City of Ontario and DOES 1 through 24 10, inclusive, United District Court, Central District, Case No. 5:26-cv-0455. 25 2.2 Challenging Party: A Party or Non-Party that challenges the 26 designation of information or items under this Order. 27 2.3 “CONFIDENTIAL” Information or Items: Information (regardless of 28 how it is generated, stored or maintained) or tangible things that qualify for 1 protection under Federal Rule of Civil Procedure 26(c), and as specified above in 2 the Good Cause Statement. 3 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as 4 their support staff). 5 2.5 Designating Party: A Party or Non-Party that designates information 6 or items that it produces in disclosures or in responses to discovery as 7 “CONFIDENTIAL.” 8 2.6 Disclosure or Discovery Material: All items or information, regardless 9 of the medium or manner in which it is generated, stored, or maintained (including, 10 among other things, testimony, transcripts, and tangible things), that are produced 11 or generated in disclosures or responses to discovery in this matter. 12 2.7 Expert: A person with specialized knowledge or experience in a 13 matter pertinent to the litigation who has been retained by a Party or its counsel to 14 serve as an expert witness or as a consultant in this Action. 15 2.8 House Counsel: Attorneys who are employees of a party to this 16 Action. House Counsel does not include Outside Counsel of Record or any other 17 outside counsel. 18 2.9 Non-Party: Any natural person, partnership, corporation, association, 19 or other legal entity not named as a Party to this action. 20 2.10 Outside Counsel of Record: Attorneys who are not employees of a 21 party to this Action but are retained to represent or advise a party to this Action 22 and have appeared in this Action on behalf of that party or are affiliated with a law 23 firm which has appeared on behalf of that party, and includes support staff. 24 2.11 Party: Any party to this Action, including all of its officers, directors, 25 employees, consultants, retained experts, and Outside Counsel of Record (and their 26 support staffs). 27 2.12 Producing Party: A Party or Non-Party that produces Disclosure or 28 Discovery Material in this Action. 1 2.13 Professional Vendors: Persons or entities that provide litigation 2 support services (e.g., photocopying, videotaping, translating, preparing exhibits or 3 demonstrations, and organizing, storing, or retrieving data in any form or medium) 4 and their employees and subcontractors. 5 2.14 Protected Material: Any Disclosure or Discovery Material that is 6 designated as “CONFIDENTIAL.” 7 2.15 Receiving Party: A Party that receives Disclosure or Discovery 8 Material from a Producing Party. 9 3. SCOPE 10 The protections conferred by this Stipulation and Order cover not only 11 Protected Material (as defined above), but also (1) any information copied or 12 extracted from Protected Material; (2) all copies, excerpts, summaries, or 13 compilations of Protected Material; and (3) any testimony, conversations, or 14 presentations by Parties or their Counsel that might reveal Protected Material. 15 Any use of Protected Material at trial shall be governed by the orders of the 16 trial judge. This Order does not govern the use of Protected Material at trial. 17 4. DURATION 18 Should any Protected Material become part of the public record at trial or 19 otherwise (such as where the Court denies the request to file under seal), this 20 Protective Order shall no longer apply to such portions at Trial which became part 21 of the public record, with the exception that all such material/documents, whether 22 part of the public record or not, must still be returned in compliance with Section 23 13: Final Disposition. Should any portion of the Protected Material remain 24 confidential until trial, during any portion of the trial of this action which could 25 entail the discussion or disclosure of Confidential Information, each Party may 26 request the opportunity to show good cause to the Court as to why access to the 27 courtroom should be limited to parties, their counsel and other designated 28 representative, experts or consultants who agreed to be bound by this 1 stipulation/protective order, and court personnel. 2 For all portions of the Protected Material after final disposition of the Trial, 3 whether they became part of the public record or not, the confidentiality 4 obligations by this Order shall remain in full effect. Final disposition shall be 5 deemed to be the later of (1) dismissal of all claims and defenses in this Action, 6 with or without prejudice; (2) In any event wherein all remaining claims in this 7 matter are remanded to State Court or severed from the Federal matter and returned 8 to State Court; and/or (3) final judgment herein after the completion and 9 exhaustion of all appeals, re-hearings, remands, trials, or reviews of this Action, 10 including the time limits for filing any motions or applications for extension of 11 time pursuant to applicable law. 12 5. DESIGNATING PROTECTED MATERIAL 13 5.1 Exercise of Restraint and Care in Designating Material for Protection. 14 Each Party or Non-Party that designates information or items for protection under 15 this Order must take care to limit any such designation to specific material that 16 qualifies under the appropriate standards. The Designating Party must designate for 17 protection only those parts of material, documents, items, or oral or written 18 communications that qualify so that other portions of the material, documents 19 items, or communications for which protection is not warranted are not swept 20 unjustifiably within the ambit of this Order. 21 Mass, indiscriminate, or routinized designations are prohibited. Designations 22 that are shown to be clearly unjustified or that have been made for an improper 23 purpose (e.g., to unnecessarily encumber the case development process or to 24 impose unnecessary expenses and burdens on other parties) may expose the 25 Designating Party to sanctions. 26 If it comes to a Designating Party’s attention that information or items that it 27 designated for protection do not qualify for protection, that Designating Party must 28 promptly notify all other Parties that it is withdrawing the inapplicable designation. 1 5.2 Manner and Timing of Designations. Except as otherwise provided in 2 this Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise 3 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection 4 under this Order must be clearly so designated before the material is disclosed or 5 produced. 6 Designation in conformity with this Order requires: 7 (a) For information in documentary form (e.g., paper or electronic 8 documents, but excluding transcripts of depositions or other pretrial or trial 9 proceedings), that the Producing Party affix at a minimum, the legend 10 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 11 contains protected material. If only a portion or portions of the material on a page 12 qualifies for protection, the Producing Party also must clearly identify the 13 protected portion(s) (e.g., by making appropriate markings in the margins). 14 A Party or Non-Party that makes original documents available for inspection 15 need not designate them for protection until after the inspecting Party has indicated 16 which documents it would like copied and produced. During the inspection and 17 before the designation, all of the material made available for inspection shall be 18 deemed “CONFIDENTIAL.” After the inspecting Party has identified the 19 documents it wants copied and produced, the Producing Party must determine 20 which documents, or portions thereof, qualify for protection under this Order. 21 Then, before producing the specified documents, the Producing Party must affix 22 the “CONFIDENTIAL legend” to each page that contains Protected Material. If 23 only a portion or portions of the material on a page qualifies for protection, the 24 Producing Party also must clearly identify the protected portion(s) (e.g., by making 25 appropriate markings in the margins). 26 (b) for testimony given in depositions that the Designating Party 27 identify the Disclosure or Discovery Material on the record, before the close of the 28 deposition all protected testimony. 1 (c) for information produced in some form other than documentary 2 andfor any other tangible items, that the Producing Party affix in a prominent place 3 on the exterior of the container or containers in which the information is stored the 4 legend “CONFIDENTIAL.” If only a portion or portions of the information 5 warrants protection, the Producing Party, to the extent practicable, shall identify 6 the protected portion(s). 7 5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 8 failure to designate qualified information or items does not, standing alone, waive 9 the Designating Party’s right to secure protection under this Order for such 10 material. Upon timely correction of a designation, the Receiving Party must make 11 reasonable efforts to assure that the material is treated in accordance with the 12 provisions of this Order. 13 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 14 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 15 designation of confidentiality at any time that is consistent with the Court’s 16 Scheduling Order. 17 6.2 Meet and Confer. The Challenging Party shall initiate the dispute 18 resolution process under Local Rule 37.1 et seq. 19 6.3 The burden of persuasion in any such challenge proceeding shall be 20 on the Designating Party. Frivolous challenges, and those made for an improper 21 purpose (e.g., to harass or impose unnecessary expenses and burdens on other 22 parties) may expose the Challenging Party to sanctions. Unless the Designating 23 Party has waived or withdrawn the confidentiality designation, all parties shall 24 continue to afford the material in question the level of protection to which it is 25 entitled under the Producing Party’s designation until the Court rules on the 26 challenge. 27 7. ACCESS TO AND USE OF PROTECTED MATERIAL 28 7.1 Basic Principles. A Receiving Party may use Protected Material that is 1 disclosed or produced by another Party or by a Non-Party in connection with this 2 Action only for prosecuting, defending, or attempting to settle this Action. Such 3 Protected Material may be disclosed only to the categories of persons and under 4 the conditions described in this Order. When the Action has been terminated, a 5 Receiving Party must comply with the provisions of section 13 below (FINAL 6 DISPOSITION). 7 Protected Material must be stored and maintained by a Receiving Party at a 8 location and in a secure manner that ensures that access is limited to the persons 9 authorized under this Order. 10 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 11 otherwise ordered by the court or permitted in writing by the Designating Party, a 12 Receiving Party may disclose any information or item designated 13 “CONFIDENTIAL” only to: 14 (a) The Receiving Party’s Outside Counsel of Record in this 15 Action, as well as employees of said Outside Counsel of Record to whom it is 16 reasonably necessary to disclose the information for this Action; 17 (b) the officers, directors, and employees (including House 18 Counsel) of the Receiving Party to whom disclosure is reasonably necessary for 19 this Action; 20 (c) Experts (as defined in this Order) of the Receiving Party to 21 whom disclosure is reasonably necessary for this Action and who have signed the 22 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 23 (d) the court and its personnel; 24 (e) court reporters and their staff; 25 (f) professional jury or trial consultants, mock jurors, and 26 Professional Vendors to whom disclosure is reasonably necessary for this Action 27 and who have signed the “Acknowledgment and Agreement to Be Bound” (Exhibit 28 A); 1 (g) the author or recipient of a document containing the 2 information or a custodian or other person who otherwise possessed or knew the 3 information; 4 (h) during their depositions, witnesses ,and attorneys for witnesses, 5 in the Action to whom disclosure is reasonably necessary provided: (1) The 6 deposing party requests that the witness sign the form attached as Exhibit 1 hereto; 7 and (2) they will not be permitted to keep any confidential information unless they 8 sign the “Acknowledgment and Agreement to Be Bound” (Exhibit A), unless 9 otherwise agreed by the Designating Party or ordered by the court. Pages of 10 transcribed deposition testimony or exhibits to depositions that reveal Protected 11 Material may be separately bound by the court reporter and may not be disclosed 12 to anyone except as permitted under this Stipulated Protective Order; and 13 (i) any mediator or settlement officer, and their supporting 14 personnel, mutually agreed upon by any of the parties engaged in settlement 15 discussions. 16 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED 17 PRODUCED IN OTHER LITIGATION 18 If a Party is served with a subpoena or a court order issued in other litigation 19 that compels disclosure of any information or items designated in this Action as 20 “CONFIDENTIAL,” that Party must: 21 (a) Promptly notify in writing the Designating Party. Such 22 notification shall include a copy of the subpoena or court order; 23 (b) promptly notify in writing the party who caused the subpoena 24 or order to issue in the other litigation that some or all of the material covered by 25 the subpoena or order is subject to this Protective Order. Such notification shall 26 include a copy of this Stipulated Protective Order; and 27 (c) cooperate with respect to all reasonable procedures sought to be 28 pursued by the Designating Party whose Protected Material may be affected. 1 If the Designating Party timely seeks a protective order, the Party served 2 with the subpoena or court order shall not produce any information designated in 3 this action as “CONFIDENTIAL” before a determination by the court from which 4 the subpoena or order issued, unless the Party has obtained the Designating Party’s 5 permission. The Designating Party shall bear the burden and expense of seeking 6 protection in that court of its confidential material and nothing in these provisions 7 should be construed as authorizing or encouraging a Receiving Party in this Action 8 to disobey a lawful directive from another court. 9 9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE 10 PRODUCED IN THIS LITIGATION 11 (a) The terms of this Order are applicable to information produced 12 by a Non-Party in this Action and designated as “CONFIDENTIAL.” Such 13 information produced by Non-Parties in connection with this litigation is protected 14 by the remedies and relief provided by this Order. Nothing in these provisions 15 should be construed as prohibiting a Non-Party from seeking additional 16 protections. 17 (b) In the event that a Party is required, by a valid discovery 18 request, to produce a Non-Party’s confidential information in its possession, and 19 the Party is subject to an agreement with the Non-Party not to produce the Non- 20 Party’s confidential information, then the Party shall: 21 (1) Promptly notify in writing the Requesting Party and the 22 Non-Party that some or all of the information requested is subject to a 23 confidentiality agreement with a Non-Party; 24 (2) promptly provide the Non-Party with a copy of the 25 Stipulated Protective Order in this Action, the relevant discovery request(s), and a 26 reasonably specific description of the information requested; and 27 (3) make the information requested available for inspection 28 by the Non-Party, if requested. 1 (c) If the Non-Party fails to seek a protective order from this court 2 within 14 days of receiving the notice and accompanying information, the 3 Receiving Party may produce the Non-Party’s confidential information responsive 4 to the discovery request. If the Non-Party timely seeks a protective order, the 5 Receiving Party shall not produce any information in its possession or control that 6 is subject to the confidentiality agreement with the Non-Party before a 7 determination by the court. Absent a court order to the contrary, the Non-Party 8 shall bear the burden and expense of seeking protection in this court of its 9 Protected Material. 10 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 11 If a Receiving Party learns that, by inadvertence or otherwise, it has 12 disclosed Protected Material to any person or in any circumstance not authorized 13 under this Stipulated Protective Order, the Receiving Party must immediately (a) 14 notify in writing the Designating Party of the unauthorized disclosures, (b) use its 15 best efforts to retrieve all unauthorized copies of the Protected Material, (c) inform 16 the person or persons to whom unauthorized disclosures were made of all the terms 17 of this Order, and (d) request such person or persons to execute the 18 “Acknowledgment and Agreement to Be Bound” that is attached hereto as Exhibit 19 A. 20 11. INADVERTENT PRODUCTION OF PRIVILEGED OR 21 OTHERWISE PROTECTED MATERIAL 22 When a Producing Party gives notice to Receiving Parties that certain 23 inadvertently produced material is subject to a claim of privilege or other 24 protection, the obligations of the Receiving Parties are those set forth in Federal 25 Rule of Civil Procedure 26(b)(5)(B). This provision is not intended to modify 26 whatever procedure may be established in an e-discovery order that provides for 27 production without prior privilege review. Pursuant to Federal Rule of Evidence 28 502(d) and (e), insofar as the parties reach an agreement on the effect of disclosure 1 of a communication or information covered by the attorney-client privilege or 2 work product protection, the parties may incorporate their agreement in the 3 stipulated protective order submitted to the court. 4 12. MISCELLANEOUS 5 12.1 Right to Further Relief. Nothing in this Order abridges the right of any 6 person to seek its modification by the Court in the future. 7 12.2 Right to Assert Other Objections. By stipulating to the entry of this 8 Protective Order no Party waives any right it otherwise would have to object to 9 disclosing or producing any information or item on any ground not addressed in 10 this Stipulated Protective Order. Similarly, no Party waives any right to object on 11 any ground to use in evidence of any of the material covered by this Protective 12 Order. 13 12.3 Filing Protected Material. A Party that seeks to file under seal any 14 Protected Material must comply with Civil Local Rule 79-5. Protected Material 15 may only be filed under seal pursuant to a court order authorizing the sealing of the 16 specific Protected Material at issue. If a Party's request to file Protected Material 17 under seal is denied by the court, then the Receiving Party may file the information 18 in the public record unless otherwise instructed by the court. 19 13. FINAL DISPOSITION 20 After the final disposition of this Action, as defined in paragraph 4, within 21 60 days of a written request by the Designating Party, each Receiving Party must 22 return all Protected Material to the Producing Party or destroy such material. As 23 used in this subdivision, “all Protected Material” includes all copies, abstracts, 24 compilations, summaries, and any other format reproducing or capturing any of the 25 Protected Material. Whether the Protected Material is returned or destroyed, the 26 Receiving Party must submit a written certification to the Producing Party (and, if 27 not the same person or entity, to the Designating Party) by the 60 day deadline that 28 (1) identifies (by category, where appropriate) all the Protected Material that was 1 returned or destroyed and (2)affirms that the Receiving Party has not retained any 2 copies, abstracts, compilations, summaries or any other format reproducing or 3 capturing any of the Protected Material. Notwithstanding this provision, Counsel 4 are entitled to retain an archival copy of all pleadings, motion papers, trial, 5 deposition, and hearing transcripts, legal memoranda, correspondence, deposition 6 and trial exhibits, expert reports, attorney work product, and consultant and expert 7 work product, even if such materials contain Protected Material. Any such archival 8 copies that contain or constitute Protected Material remain subject to this 9 Protective Order as set forth in Section 4 (DURATION). 10 14. VIOLATION 11 Any violation of this Order may be punished by any and all appropriate 12 measures including, without limitation, contempt proceedings and/or monetary 13 sanctions. 14 IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD. 15 DATED: June 4, 2026 LAW OFFICE OF JAMES S. TERRELL

16 By: /s/ James S. Terrell 17 James S. Terrell, Esq. Attorneys for 18 GABRIEL HERNANDEZ 19 DATED: June 4, 2026 LAW OFFICE OF SHARON J. BRUNNER 20

21 By: /s/ Sharon J. Brunner Sharon J. Brunner, Esq. 22 Attorneys for Plaintiff GABRIEL HERNANDEZ 23 DATED: June 4, 2026 JONES MAYER 24

25 By: /s/ Thurgood M. Wynn James R. Touchstone, Esq. 26 Thurgood M. Wynn, Esq. Attorneys for Defendant 27 CITY OF ONTARIO 28 l ORDER 2 FOR GOOD CAUSE SHOWN, IT IS SQ.ORDERE Dated: June 8, 2026 . / 4 patie (be 5 UNITED STATES MAGISTRATE JUDGE 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 -15-

1 EXHIBIT A 2 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND 3 I, _____________________________ [print or type full name], of 4 _________________ [print or type full address], declare under penalty of perjury 5 that I have read in its entirety and understand the Stipulated Protective Order that 6 was issued by the United States District Court for the Central District of California 7 on ________ in the case of Gabriel Hernandez v. City of Ontario, et al., Case No. 8 Case No.: 5:26-cv-00455-DTB. I agree to comply with and to be bound by all the 9 terms of this Stipulated Protective Order and I understand and acknowledge that 10 failure to so comply could expose me to sanctions and punishment in the nature of 11 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 13 or 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 15 Court for the Central District of California for the purpose of enforcing the terms 16 of this Stipulated Protective Order, even if such enforcement proceedings occur 17 after termination of this action. I hereby appoint __________________________ 18 [print or type full name] of _______________________________________ [print 19 or type full address and telephone number] as my California agent for service of 20 process in connection with this action or any proceedings related to enforcement of 21 this Stipulated Protective Order. 22 Date: ______________________________________ 23 City and State where sworn and signed: _________________________________ 24 Printed name: _______________________________ 25 Signature: __________________________________ 26 27 28