1 || ROBERT W. FREEMAN Nevada Bar No. 3062 2 || Robert.Freeman@lewisbrisbois.com E. MATTHEW FREEMAN 3 || Nevada Bar No. 14198 Matt.Freeman@lewisbrisbois.com 4 || LEWIS BRISBOIS BISGAARD & SMITH LLP 6385 S. Rainbow Boulevard, Suite 600 5 || Las Vegas, Nevada 89118 702.893.3383 6 || FAX: 702.893.3789 Attorneys for Defendants 7 || Police Officer Sergio Lopez, Police Officer Trevor Rundus and 8 || Police Officer Lorson Kade 9 UNITED STATES DISTRICT COURT 10 DISTRICT OF NEVADA 11 ee 12 || MICKYAS BERHANEMESKEL, CASE NO. 2:24-cv-1371-JAD-DJA 13 Plaintiff, STIPULATED PROTECTIVE ORDER AND CONFIDENTIALITY AGREEMENT 14 vs. 15 || S. LOPEZ, T. RUNDUS, LORSON KADE, As amended on page 8 16 Defendants. 17 18 The parties to this action, by their respective counsel, having agreed to the following, and 19 || for good cause shown pursuant to Fed. R. Civ. P 26(c)(1), IT IS HEREBY ORDERED as follows: 20 1. PURPOSES AND LIMITATIONS. 21 Disclosure and discovery activity in this action may involve production of confidential, 22 || proprietary, or private information for which special protection from public disclosure may be 23 || warranted pursuant to Rule 26(c)(1) of the Federal Rules of Civil Procedure. The parties 24 || acknowledge that this Order does not confer blanket protections on all disclosures or responses to 25 || discovery and that the protection it affords extends only to the limited information or items that 26 || are entitled under law to treatment as confidential. 27 2. SCOPE. 28 All documents produced in the course of discovery, all responses to discovery requests,
1 || and all deposition testimony and exhibits and any other materials which may be subject to 2 || discovery (hereinafter collectively “Discovery Material”) shall be subject to this stipulated 3 || protective order concerning confidential information as set forth below. Any party, or any third 4 || party who produces documents in this litigation, may designate documents as Confidential but 5 || only after review of the documents by an attorney who has, in good faith, determined that the 6 || documents contain “Confidential Information,” as defined below, and pursuant to the procedure 7 || set forth below. 8 3. CONFIDENTIAL INFORMATION. 9 “Confidential Information” shall mean information meriting special protection under the 10 || Federal Rules of Civil Procedure and applicable case law. Confidential Information does not 11 || include information that: (a) is in the public domain at the time of disclosure; (b) becomes part of 12 || the public domain through no fault of the Receiving Party; (c) the Receiving Party can show was 13 || already in its rightful and lawful possession at the time of disclosure; or (d) the Receiving Party 14 || lawfully receives from a Non-party later without restriction as to disclosure. 15 4, OTHER DEFINITIONS. 16 Party: any party to this action, including all of its officers, directors, agents, and attorney(s) 17 || of record for a Party in this action (including their associates, paralegals, and support/clerical 18 || staff). 19 Non-party: any individual, corporation, association, or natural person or entity other than a 20 || party. 21 Protected Material: any Discovery Material containing Confidential Information that is 22 || designated by a Party or Non-party as “CONFIDENTIAL,” unless the Receiving Party challenges 23 || the confidentiality designation and (a) the Court decides such material is not entitled to protection 24 || as confidential; (b) the Designating Party fails to apply the Court for an order designating the 25 || material confidential within the time period specified below; or (c) the Designating Party 26 || withdraws its confidentiality designation in writing. 27 Producing Party: a Party or Non-party that produces Discovery Material in this action. 28 Receiving Party: a Party that receives Discovery Material from a Producing Party.
1 Designating Party: a Party or Non-party that designates Discovery Material as 2 ||“CONFIDENTIAL”. The Party or Non-party designating information or items as Protected 3 || Material bears the burden of establishing good cause for the confidentiality of all such items. 4 Challenging Party: a party that elects to initiate a challenge to a Designating Party’s 5 || confidentiality designation. 6 5, FORM AND TIMING OF DESIGNATION, 7 Protected Material shall be so designated by the Producing Party by placing or affixing the 8 || word “CONFIDENTIAL” on the document in a manner which will not interfere with the legibility 9 || of the document and which will permit complete removal of the “Confidential” designation. 10 || Documents shall be designated “Confidential” prior to, or contemporaneously with, the production 11 || or disclosure of the documents. 12 A Designating Party must exercise restraint and make good faith efforts to limit 13 || CONFIDENTIAL designations to specific materials that qualify for protection under the 14 || appropriate standard. Further, a Designating Party must use good faith efforts to designate for 15 || protection only those parts of material, documents, items, or communications that qualify — so that 16 || other portions of the materials, documents, items, or communications for which protection is not 17 || warranted are not swept unjustifiably within the ambit of this Order. If only a portion or portions 18 || of materials on a page or within a document merit protection, a Producing Party must so indicate 19 || by making appropriate markings in the margins but not over text. 20 A Producing Party that makes original documents or materials available for inspection 21 || need not designate them for protection until after the inspecting Party has indicated which material 22 || it would like copied and produced. During the inspection and before the designation, all of the 23 || material made available for inspection shall be deemed “Confidential.” After the inspecting Party 24 || has identified the documents it wants copied and produced, the Producing Party must determine 25 || which documents, or portions thereof, qualify for protection under this Order, and, before 26 || producing the specified documents, the Producing Party must affix the appropriate legend on each 27 || page that contains Protected Material. If only a portion or portions of the material on a page 28 || qualifies for protection, the Producing Party also must clearly identify the protected
1 || portion(s) (e.g., by making appropriated markings in the margins or by redacting protected 2 || portions). 3 Portions of depositions shall be designated Confidential when the deposition is taken or 4 || within fourteen (14) business days after receipt of the transcript, if feasible. Such designation shall 5 || be specific as to the pages and lines to be protected. A Designating Party must exercise restraint 6 || and make good faith efforts to limit “CONFIDENTIAL” designations to specific testimony or 7 || materials that qualify for protection under the appropriate standards. 8 Inadvertent or unintentional production of Protected Material without prior designation as 9 ||“Confidential” shall not be deemed a waiver, in whole or in part, of the right to designate 10 || documents as Protected Material as otherwise allowed by this Order. Further, a Party may assert 11 || that disclosures or discovery material produced by another Party constitute Protected Material by 12 || informing the opposing Party by following the procedures set forth herein for a Designated Party. 13 6. Protection of PROTECTED Material. 14 a. General Protections.
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1 || ROBERT W. FREEMAN Nevada Bar No. 3062 2 || Robert.Freeman@lewisbrisbois.com E. MATTHEW FREEMAN 3 || Nevada Bar No. 14198 Matt.Freeman@lewisbrisbois.com 4 || LEWIS BRISBOIS BISGAARD & SMITH LLP 6385 S. Rainbow Boulevard, Suite 600 5 || Las Vegas, Nevada 89118 702.893.3383 6 || FAX: 702.893.3789 Attorneys for Defendants 7 || Police Officer Sergio Lopez, Police Officer Trevor Rundus and 8 || Police Officer Lorson Kade 9 UNITED STATES DISTRICT COURT 10 DISTRICT OF NEVADA 11 ee 12 || MICKYAS BERHANEMESKEL, CASE NO. 2:24-cv-1371-JAD-DJA 13 Plaintiff, STIPULATED PROTECTIVE ORDER AND CONFIDENTIALITY AGREEMENT 14 vs. 15 || S. LOPEZ, T. RUNDUS, LORSON KADE, As amended on page 8 16 Defendants. 17 18 The parties to this action, by their respective counsel, having agreed to the following, and 19 || for good cause shown pursuant to Fed. R. Civ. P 26(c)(1), IT IS HEREBY ORDERED as follows: 20 1. PURPOSES AND LIMITATIONS. 21 Disclosure and discovery activity in this action may involve production of confidential, 22 || proprietary, or private information for which special protection from public disclosure may be 23 || warranted pursuant to Rule 26(c)(1) of the Federal Rules of Civil Procedure. The parties 24 || acknowledge that this Order does not confer blanket protections on all disclosures or responses to 25 || discovery and that the protection it affords extends only to the limited information or items that 26 || are entitled under law to treatment as confidential. 27 2. SCOPE. 28 All documents produced in the course of discovery, all responses to discovery requests,
1 || and all deposition testimony and exhibits and any other materials which may be subject to 2 || discovery (hereinafter collectively “Discovery Material”) shall be subject to this stipulated 3 || protective order concerning confidential information as set forth below. Any party, or any third 4 || party who produces documents in this litigation, may designate documents as Confidential but 5 || only after review of the documents by an attorney who has, in good faith, determined that the 6 || documents contain “Confidential Information,” as defined below, and pursuant to the procedure 7 || set forth below. 8 3. CONFIDENTIAL INFORMATION. 9 “Confidential Information” shall mean information meriting special protection under the 10 || Federal Rules of Civil Procedure and applicable case law. Confidential Information does not 11 || include information that: (a) is in the public domain at the time of disclosure; (b) becomes part of 12 || the public domain through no fault of the Receiving Party; (c) the Receiving Party can show was 13 || already in its rightful and lawful possession at the time of disclosure; or (d) the Receiving Party 14 || lawfully receives from a Non-party later without restriction as to disclosure. 15 4, OTHER DEFINITIONS. 16 Party: any party to this action, including all of its officers, directors, agents, and attorney(s) 17 || of record for a Party in this action (including their associates, paralegals, and support/clerical 18 || staff). 19 Non-party: any individual, corporation, association, or natural person or entity other than a 20 || party. 21 Protected Material: any Discovery Material containing Confidential Information that is 22 || designated by a Party or Non-party as “CONFIDENTIAL,” unless the Receiving Party challenges 23 || the confidentiality designation and (a) the Court decides such material is not entitled to protection 24 || as confidential; (b) the Designating Party fails to apply the Court for an order designating the 25 || material confidential within the time period specified below; or (c) the Designating Party 26 || withdraws its confidentiality designation in writing. 27 Producing Party: a Party or Non-party that produces Discovery Material in this action. 28 Receiving Party: a Party that receives Discovery Material from a Producing Party.
1 Designating Party: a Party or Non-party that designates Discovery Material as 2 ||“CONFIDENTIAL”. The Party or Non-party designating information or items as Protected 3 || Material bears the burden of establishing good cause for the confidentiality of all such items. 4 Challenging Party: a party that elects to initiate a challenge to a Designating Party’s 5 || confidentiality designation. 6 5, FORM AND TIMING OF DESIGNATION, 7 Protected Material shall be so designated by the Producing Party by placing or affixing the 8 || word “CONFIDENTIAL” on the document in a manner which will not interfere with the legibility 9 || of the document and which will permit complete removal of the “Confidential” designation. 10 || Documents shall be designated “Confidential” prior to, or contemporaneously with, the production 11 || or disclosure of the documents. 12 A Designating Party must exercise restraint and make good faith efforts to limit 13 || CONFIDENTIAL designations to specific materials that qualify for protection under the 14 || appropriate standard. Further, a Designating Party must use good faith efforts to designate for 15 || protection only those parts of material, documents, items, or communications that qualify — so that 16 || other portions of the materials, documents, items, or communications for which protection is not 17 || warranted are not swept unjustifiably within the ambit of this Order. If only a portion or portions 18 || of materials on a page or within a document merit protection, a Producing Party must so indicate 19 || by making appropriate markings in the margins but not over text. 20 A Producing Party that makes original documents or materials available for inspection 21 || need not designate them for protection until after the inspecting Party has indicated which material 22 || it would like copied and produced. During the inspection and before the designation, all of the 23 || material made available for inspection shall be deemed “Confidential.” After the inspecting Party 24 || has identified the documents it wants copied and produced, the Producing Party must determine 25 || which documents, or portions thereof, qualify for protection under this Order, and, before 26 || producing the specified documents, the Producing Party must affix the appropriate legend on each 27 || page that contains Protected Material. If only a portion or portions of the material on a page 28 || qualifies for protection, the Producing Party also must clearly identify the protected
1 || portion(s) (e.g., by making appropriated markings in the margins or by redacting protected 2 || portions). 3 Portions of depositions shall be designated Confidential when the deposition is taken or 4 || within fourteen (14) business days after receipt of the transcript, if feasible. Such designation shall 5 || be specific as to the pages and lines to be protected. A Designating Party must exercise restraint 6 || and make good faith efforts to limit “CONFIDENTIAL” designations to specific testimony or 7 || materials that qualify for protection under the appropriate standards. 8 Inadvertent or unintentional production of Protected Material without prior designation as 9 ||“Confidential” shall not be deemed a waiver, in whole or in part, of the right to designate 10 || documents as Protected Material as otherwise allowed by this Order. Further, a Party may assert 11 || that disclosures or discovery material produced by another Party constitute Protected Material by 12 || informing the opposing Party by following the procedures set forth herein for a Designated Party. 13 6. Protection of PROTECTED Material. 14 a. General Protections. Protected Material shall not be used or disclosed by the parties or 15 || counsel for the parties or any other persons identified below ({ 6(b)) for any purposes whatsoever 16 || other than preparing for and conducting litigation in the above-entitled action (including any 17 || appeal) and resolving any third party claims including, without limitation, Medicare and Medicaid. 18 b. Qualified Receiving Parties and Limited Third Party Disclosures. Protected 19 || Material shall be held in confidence by each qualified Receiving Party to whom it is disclosed, 20 || shall be used only for purposes of this action, and shall not be disclosed to any person who is not a 21 || qualified recipient. All Protected Material shall be carefully maintained so as to preclude access by 22 || persons who are not qualified Receiving Parties. 23 Subject to these requirements, in addition to Parties and the Court, the following categories 24 || of persons may be allowed to review Protected Material pursuant to this Order subject to 25 || executing an acknowledgment (in the form set forth at Exhibit A hereto), that he or she has read 26 || and understands the terms of this Order and is bound by it: 27 (1) Any officers, directors, or designated employees of a Party deemed 28 necessary by counsel of record in this action to aid in the prosecution,
1 defense, or settlement of this action; 2 (2) Professional outside vendors for attorneys of record (such as copying 3 services and translators and interpreters), 4 (3) Court reporters, deposition notaries and staff; 5 (4) The author of any document designated as CONFIDENTIAL or the original 6 source of Confidential Information contained therein; 7 (5) Persons other than legal counsel who have been retained or specially 8 employed by a party as an expert witness for purposes of this lawsuit or to 9 perform investigative work or fact research; 10 (6) Deponents during the course of their depositions; 11 (7) Counsel for issuers of insurance policies under which any issuer may be 12 liable to satisfy part or all of a judgment that may be entered in these 13 proceedings or indemnify or reimburse payments or costs associated with 14 these proceedings; 15 (8) Any private mediator or arbitrator appointed by the Court or selected by 16 mutual agreement of the parties; 17 (9) Any other person as to whom the Producing Party has consented to 18 disclosure in advance and in writing, on notice to each Party hereto. 19 ce. Control of Documents. Counsel for Parties shall take reasonable efforts to prevent 20 || unauthorized disclosure of Protected Material pursuant to the terms of this Order. No copies of 21 || Protected Material shall be made except by or on behalf of attorneys of record, in-house counsel or 22 || the parties in this action. 23 d. Copies. Any person making copies of Protected Material shall maintain all copies 24 || within their possession or the possession of those entitled to access to such information under the 25 || Protective Order. All copies shall be immediately affixed with the designation 26 “CONFIDENTIAL” if the word does not already appear on the copy. All such copies shall be 27 || afforded the full protection of this Order. 28 ||...
1 7, UNAUTHORIZED DISCLOSURE. 2 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed Protected 3 || Material to any person or in any circumstance not authorized under this Stipulated Protective 4 || Order, the Receiving Party must immediately (a) notify in writing the Designating Party of the 5 || unauthorized disclosures, (b) use its best efforts to retrieve all copies of the Protected Material, (c) 6 || inform the person or persons to whom unauthorized disclosures were made of all the terms of this 7 || Order, and (d) request such person or persons to execute the “Acknowledgment and Agreement to 8 || Be Bound by Stipulated Protective Order” (Exhibit A). 9 8. Filing PROTECTED Material 10 The Parties recognize the presumption of public access inherent in judicial records and that 11 || a Protective Order does not establish that documents meet the “standard for sealing set forth in the 12 || Ninth Circuit’s decisions in Kamakana v. City and County of Honolulu, 447 F.3d 1172 (9th Cir. 13 || 2006) and Cir. for Auto Safety v. Chrysler Group, LLC, 809 F.3d 1092, 1097 (9th Cir. 2016), cert. 14 || denied sub nom. FCA U.S. LLC v. Ctr. for Auto Safety, 137 S. Ct. 38 (2016). “A party seeking to 15 || seal a judicial record then bears the burden of overcoming this strong presumption by meeting the 16 || ‘compelling reasons’ standard.” Kamakana, 447 F.3d at 1178. The only exception to this rule is 17 || that only good cause need be established “for sealed materials attached to a discovery motion 18 || unrelated to the merits of a case.” Chrysler Group 809 F. 3d at 1097 (citing Phillips ex rel. Estates 19 || of Byrd v. Gen. Motors Corp., 307 F.3d 1206, 1213-14 (9th Cir.2002).). Further, the Court should 20 || make an independent determination regarding whether documents merit sealed status, and thus 21 || expressly reserves the right to do so. Kamakana 447 F.3d at 1186-87. 22 In recognition of this legal standard, and the fact that the party filing Protected Material 23 || may not be the party that designated it confidential (and thus, may not believe good cause exists 24 || for sealing), the Parties suggest that the procedure set forth below is followed if the sole ground 25 || for a motion to seal is that the opposing party (or non-party) has designated a document as subject 26 || to protection pursuant to this Stipulated Protective Order: The Party filing such Protected 27 || Materials may assert in the accompanying motion any reasons why the Protected Materials should 28 || not, in fact, be kept under seal and the Designating Party, who must be properly noticed, may
1 || likewise file a response asserting its position that the Protected Material merits protection under 2 || Rule 26(c) of the Federal Rules of Civil Procedure and attaching a declaration supporting the 3 || assertion that the designated material meets the applicable standard. 4 9. Challenges to PROTECTED MATERIAL. 5 Any designation of Protected Material is subject to challenge. The following procedures 6 || shall apply to any such challenge: 7 a. Burden. The burden of proving the necessity of a “CONFIDENTIAL” designation 8 ||remains with the party asserting confidentiality. 9 b. Notice; Opportunity to Challenge. A party who contends that Protected Material is not 10 || entitled to confidential treatment shall give written notice to the party who affixed the 11 || “CONFIDENTIAL.” designation of the specific basis for the challenge. The party who so 12 || designated the documents shall have fourteen (14) days from service of the written notice to 13 || determine if the dispute can be resolved without judicial intervention and, if not, to move for an 14 || Order confirming the “CONFIDENTIAL” designation, and the status as Protected Material. 15 c. Treatment as Protected Material until Order or Withdrawal. Notwithstanding any 16 || challenge to the designation of documents as such, all material previously designated 17 || “CONFIDENTIAL.” shall continue to be treated as Protected Material subject to the full 18 || protections of this Order until one of the following occurs: (1) the Party who claims that the 19 || documents are Protected Material withdraws such designation in writing; (2) the Party who claims 20 || that the documents are confidential fails to move timely for an Order designating the documents as 21 || confidential as set forth in paragraph 9.b. above; or (3) the Court rules that the documents are not 22 || Protected Material and/or should no longer be designated as “Confidential.” 23 10. DURATION; Conclusion of Litigation. 24 All provisions of this Order restricting the use of Protected Material shall continue to be 25 || binding after the conclusion of the litigation unless otherwise agreed or ordered. However, the 26 || dismissal of this action will terminate the jurisdiction of this Court, including over this Order. 27 || Within sixty (60) days of the final termination of the above-entitled action, which would be either 28 || a final judgment on all claims or stipulation and order for dismissal with prejudice, all documents
1 || and information designated as CONFIDENTIAL by a Designating Party and which has not been 2 || challenged, including any copies, or documents containing information taken therefrom, shall be 3 || returned to the Designating Party. In the alternative, within sixty (60) days of the final termination 4 || of this case, which would be either a final judgment on all claims or stipulation and order for 5 || dismissal with prejudice, all such documents, including copies, may be shredded or disposed of in 6 a manner to ensure the destruction thereof. To the extent a party has designated portions of a 7 || deposition transcript as CONFIDENTIAL, the non-designating party is under no obligation or 8 || duty to shred or dispose of the deposition transcript, or any portion thereof, however, the 9 || CONFIDENTIAL designation will remain. 10 11. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED 11 IN OTHER LITIGATION. 12 If a Party is served with a subpoena or an order issued in other litigation that would compel 13 || disclosure of Protected Material designated by another Party or Non-party, the Party must so 14 || notify the Designating Party, in writing (by e-mail or fax, if possible) within three (3) court days 15 || after receiving the subpoena or order. Such notification must include a copy of the subpoena or 16 || court order. 17 12. ORDER SUBJECT TO MODIFICATION. 18 This Order shall be subject to modification on motion of any Party or any other person 19 || who may show an adequate interest in in the above-entitled action to intervene for purposes of 20 || addressing the scope and terms of this Order. The Order shall not, however, be modified until the 21 || Parties shall have been given notice and an opportunity to be heard on the proposed modification. However, the Court may modify the Order sua sponte without notice. 22 13. NO JUDICIAL DETERMINATION, 23 This Order is entered based on the representations and agreements of the Parties and for 24 || the purpose of facilitating discovery. Nothing herein shall be construed or presented as a judicial 25 || determination that any specific document or item of information designated as CONFIDENTIAL 26 || by counsel is subject to protection under Rule 26(c) of the Federal Rules of Civil Procedure or 27 || otherwise until such time as a document-specific ruling shall have been made. 28 || ...
1 14. MISCELLANEOUS. 2 a. Public Health and Safety. Nothing in this Order is intended to prevent any Party from 3 || raising with the Court any concern that the non-disclosure of certain Protected Material may have 4 || a possible adverse effect upon the general public health or safety, or the administration or 5 || operation of government or public office. 6 b. Right to Further Relief. Nothing is this Order abridges the right of any Party or person 7 to seek its modification by the Court in the future. 8 c. Right to Assert Other Objections. By stipulating to the entry of this Order, no Party 9 || waives any right it otherwise would have to object to disclosing or producing any information or 10 || item on any ground not addressed in this 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 Order. ||... 13 ||... 14]|... 15]}... |)... ||... 18 ||... ||... |)... 21/||... 22 ||... 23 ||... 24}... 25 ||... 26 ||... ||... 28 ||...
1 15. PERSONS BOUND UPON ENTRY OF ORDER. 2 This Order shall take effect when entered and shall be immediately binding upon the 3 || Parties (as defined herein). 4 IT IS SO STIPULATED. 5 || DATED the Io day of October, 2025. DATED the _17thday of October, 2025. 6 || MICKYAS BBRH XNEMESKE i fy EWIS BRISBOIS BISGAARD & SMITH, LLP 7 / Uf GY, 1A, SY YY E. Matthew Freeman 3 WIGKYAS BERHANEMESKEL ROBERT W. FREEMAN 4 {281818 Nevada Bar No.: 3062 9 Southern Desert Correctional Center E. MATTHEW FREEMAN P.O. Box 208 Nevada Bar No.: 14198 10 || Indian Springs, NV 89070-0208 6385 S. Rainbow Blvd., Ste. 600 Plaintiff in Proper Person Las Vegas, Nevada 89118 Attorneys for Metro Defendants 12 13 ORDER 14 IT IS SO ORDERED. 15 16 \
17 DANIEL J. ALBREGTS) UNITED STATES MAGISTRATE JUDGE 19 DATED: October 20, 2025 20 21 22 23 24 25 26 27 8
EXHIBIT A
3 ACKNOWLEDGMENT OF RECEIPT AND
4 AGREEMENT TO COMPLY WITH
STIPULATED CONFIDENTIALITY AGREEMENT AND
‘ PROTECTIVE ORDER
7 The undersigned, \\ okyas : ventory acknowledges that he/she has 8 || been provided with a copy of the Parties’ Stipulated Confidentiality Agreement and Protective 9 || Order entered in the case no. 2:24-cv-1371-JAD-DJA, captioned MICKYAS BERHANEMESKEL 10 ||». SERGIO LOPEZ, ET. AL., in the United States District Court, District of Nevada, Southern 11 || Division. The undersigned has reviewed said Stipulated Confidentiality Agreement and Protective 12 || Order and hereby agrees to be bound by the terms thereof. 13 DATED this \S day of _Cetobey _, 2025 ty 7 off sa f, 16 i (ation Pa ffran — Signature 17 Vuickiass ase) yl pac hs 18 Name (Printed) 19 SOCL Po Rx 20% 20 Street Address 21 Sepa “Pere? □□□ RISO & 22 City State Zip 23 24 Occupation / Business 25 26 27 8