Sade Thompson v. County of Los Angeles

• Court: District Court, C.D. California
• Decided: June 26, 2025
• Docket: 2:24-cv-10252
• Status: Unknown

Opinion

1 Thomas C. Hurrell, State Bar No. 119876 E-Mail: thurrell@hurrellcantrall.com 2 Jordan S. Stern, State Bar No. 311527 E-Mail: jstern@hurrellcantrall.com 3 HURRELL CANTRALL LLP 725 S. Figueroa Street, Suite 3800 4 Los Angeles, California 90017 Telephone: (213) 426-2000 5 Facsimile: (213) 426-2020 6 Attorneys for Defendants, COUNTY OF LOS ANGELES, YADIRA CERVANTES, SGT. OSCAR MEDINA and SGT. OGUNJUMO 7 ROBERT S. BROWN, Esq. 8 ROBERT STANFORD BROWN, APC 714 W. Olympic Blvd Suite 450 9 Los Angeles, CA 90015 10 Tel: (213) 745-6300; Fax: (213) 261-3906 Email: rstanfordbrown@gmail.cm 11 12 Attorneys for Plaintiff SADE THOMPSON 13 14 UNITED STATES DISTRICT COURT 15 CENTRAL DISTRICT OF CALIFORNIA, WESTERN DIVISION 16 17 18 SADE THOMPSON, Case No. 2:24-cv-10252-SRM-SSCx 19 Plaintiff, STIPULATED [PROPOSED] PROTECTIVE ORDER 20 v. GOVERNING PRODUCTION OF "CONFIDENTIAL" 21 COUNTY OF LOS ANGELES, a INFORMATION public entity, YADIRA CERVANTES, 22 SGT. OSCAR MEDINA, SGT. OGUNJUMO and DOES 1 through 10, [Assigned to Hon. Serena R. Murillo, 23 Inclusive, Courtroom "5D"] 24 Defendants. 25 26 27 1 I. PURPOSE AND LIMITATIONS 2 Discovery in this action is likely to involve production of confidential or private 3 information for which special protection from public disclosure and from use for any 4 purpose other than prosecuting this action may be warranted. Accordingly, the parties 5 hereby stipulate to and petition the Court to enter the following [Proposed] Stipulated 6 Protective Order (hereafter “this Order”). The parties acknowledge that this Order 7 does not confer blanket protections on all disclosures or responses to discovery; and 8 that the protection it affords from public disclosure and use extends only to the limited 9 information or items that are entitled to confidential treatment under the applicable 10 legal principles. 11 II. GOOD CAUSE STATEMENT 12 This action is likely to involve confidential information pertaining to personnel 13 records and other materials subject to privacy protections for which special protection 14 from public disclosure and from use for any purpose other than prosecution of this 15 action is warranted. Limiting disclosure of these documents to the context of this 16 litigation as provided herein will, accordingly, further important law enforcement 17 objectives and interests, including the safety of personnel and the public, as well as 18 the privacy rights of plaintiff, the individual defendants, and third party witnesses. 19 Such confidential materials and information consists of, among other things, materials 20 entitled to privileges and/or protections under the following: the United States 21 Constitution, First Amendment; the California Constitution, Article I, Section 1; 22 California Penal Code §§ 832.5, 832.7, and 832.8; California Evidence Code §§ 1040 23 and 1043, et seq.; the Privacy Act of 1974, 5 U.S.C. § 552a; Health Insurance 24 Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, decisional 25 law relating to such provisions; and information otherwise generally unavailable to 26 the public; or which may be privileged or otherwise protected from disclosure under 27 state or federal statutes, court rules, case decisions, or common law. Defendants also 1 to the Official Information Privilege. 2 Confidential information with respect to the Defendants may include: 3 personnel files; internal investigative files and documents; email and written 4 correspondence records; and policies and procedures that are kept from the public in 5 the ordinary course of business, as well as other items subject to the Official 6 Information Privilege and other privileges. Confidential information with respect to 7 the Plaintiff may include: employment and financial records; email and written 8 correspondence records; and psychological notes, evaluations, and report and 9 treatment plans relating to the treatment, care, and evaluation of the Plaintiff. 10 The parties reserve the right to challenge a designation of confidentiality 11 pursuant to the terms set forth under Paragraph 8 of this Order. 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 to reasonably use such material in preparation for and in conduct 16 of trial; to address their handling at the end of the litigation; and serve the ends of 17 justice, a protective order for such information is justified in this matter. It is the 18 intent of the parties that information will not be designated as confidential for tactical 19 reasons and that nothing be so designated without a good faith belief that it has been 20 maintained in a confidential, non-public manner; and there is good cause why it 21 should not be part of the public record of this case. 22 III. ACKNOWLEDGMENT OF PROCEDURE FOR FILING UNDER 23 SEAL 24 The parties further acknowledge, as set forth in Section 14.3, below, that this 25 Order does not entitle them to file confidential information under seal; Local Civil 26 Rule 79-5 sets forth the procedures that must be followed and the standards that will 27 be applied when a party seeks permission from the court to file material under seal. 1 proceedings and records in civil cases. In connection with non-dispositive motions, 2 good cause must be shown to support a filing under seal. See Kamakana v. City and 3 County of Honolulu, 447 F.3d 1172, 1176 (9th Cir. 2006), Phillips v. Gen. Motors 4 Corp., 307 F.3d 1206, 1210-11 (9th Cir. 2002), Makar-Welbon v. Sony Electrics, Inc., 5 187 F.R.D. 576, 577 (E.D. Wis. 1999) (even stipulated protective orders require good 6 cause showing, and a specific showing of good cause or compelling reasons with 7 proper evidentiary support and legal justification, must be made with respect to 8 material that a party seeks to file under seal). The parties’ mere designation of 9 material as “CONFIDENTIAL” does not— without the submission of competent 10 evidence by declaration, establishing that the material sought to be filed under seal 11 qualifies as confidential, privileged, or otherwise protectable—constitute good cause. 12 Further, if a party requests sealing related to dispositive motion or trial, then 13 compelling reasons, not only good cause, for the sealing must be shown, and the relief 14 sought shall be narrowly tailored to serve the specific interest to be protected. See 15 Pintos v. Pacific Creditors Ass’n, 605 F.3d 665, 677-79 (9th Cir. 2010). 16 Any document that is not confidential, privileged, or otherwise protectable in 17 its entirety will not be filed under seal if the confidential portions can be redacted. If 18 documents can be redacted, then a redacted version for public viewing, omitting only 19 the confidential, privileged, or otherwise protectable portions of the document, shall 20 be filed. Any application that seeks to file documents under seal in their entirety 21 should include an explanation of why redaction is not feasible. 22 IV. DEFINITIONS 23 4.1 Action: Sade Thompson v. County of Los Angeles, et al. Case No. 2:24- 24 cv-10252-SRM-SSCx. 25 4.2 Challenging Party: a Party or Non-Party that challenges the designation 26 of information or items under this Order. 27 4.3 “CONFIDENTIAL” Information or Items: Information (regardless of 1 things that qualify for protection under Federal Rule of Civil Procedure 26(c), and as 2 specified above in the Good Cause Statement. 3 4.4 Counsel: General Counsel of Record and House Counsel (as well as 4 their support staff). 5 4.5 Designating Party: a Party or Non-Party that designated information or 6 items that it produces in disclosures or in responses to discovery as 7 “CONFIDENTIAL.” 8 4.6 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 or 11 generated in disclosures or responses to discovery in this matter. 12 4.7 Expert: a person with specialized knowledge or experience in a matter 13 pertinent to the litigation who has been retained by a Party or its counsel to serve as 14 an expert witness or as a consultant in this Action. 15 4.8 House Counsel: attorneys who are employees of a party to this Action. 16 House Counsel does not include General Counsel of Record or any other outside 17 Counsel. 18 4.9 Non-Party: any natural person, partnership, corporation, association or 19 other legal entity not named as a Party to this action. 20 4.10 General Counsel of Record: attorneys who are not employees of a Party 21 to this Action but are retained to represent or advise a Party to this Action and have 22 appeared in this Action on behalf of that party or are affiliated with a law firm that 23 has appeared on behalf of that Party, as well as their support staff. 24 4.11 Party: any Party to this Action, including all of its officers, directors, 25 employees, consultants, retained experts, and General Counsel of Record (and their 26 support staffs). 27 4.12 Producing Party: a Party or Non-Party that makes a Disclosure or 1 4.13 Professional Vendors: persons or entities that provide litigation support 2 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 4.14 Protected Material: any Disclosure or Discovery Material that is 6 designated as “CONFIDENTIAL.” 7 4.15 Producing Party: a Party that makes a Disclosure or produces Discovery 8 Material to the Receiving Party. 9 4.15 Receiving Party: a Party that receives a Disclosure or Discovery 10 Material from a Producing Party. 11 V. SCOPE 12 The protections conferred by this Stipulation and Order cover not only 13 Protected Material (as defined above), but also (1) any information copied or extracted 14 from Protected Material; (2) all copies, excerpts, summaries, or compilations of 15 Protected Material; and (3) any testimony, conversations, or presentations by Parties 16 or their Counsel (as defined by Sections 4.8 and 4.10) that might reveal Protected 17 Material. 18 Any use of Protected Material at trial shall be governed by the orders of the 19 trial judge. This Order does not govern the use of Protected Material at trial. 20 VI. DURATION 21 The confidentiality obligations imposed by this Order shall remain in effect 22 until Final Disposition of this case. “Final Disposition” shall be deemed to be the 23 later of (1) dismissal of all claims and defenses in this Action, with or without 24 prejudice; and (2) final judgment herein after the completion and exhaustion of all 25 appeals, rehearings, remands, trials, or reviews of this Action, including the time 26 limits for filing any motions or applications for extension of time pursuant to 27 applicable law. 1 VII. DESIGNATING PROTECTED MATERIAL 2 7.1 Exercise of Restraint and Care in Designating Material for Protection. 3 Each Party or Non-Party that designates information or items for protection under 4 this Order must take care to limit any such designation to specific material that 5 qualifies under the appropriate standards. The Designating Party must designate for 6 protection only those parts of material, documents, items or oral or written 7 communications that qualify so that other portions of the material, documents, items 8 or communications for which protection is not warranted are not swept unjustifiably 9 within the ambit of this Order. 10 Mass, indiscriminate, or routinized designations are prohibited. Designations 11 that are shown to be clearly unjustified or that have been made for an improper 12 purpose (e.g., to unnecessarily encumber the case development process or to impose 13 unnecessary expenses and burdens on other parties) may expose the Designating Party 14 to sanctions. 15 If it comes to a Designating Party’s attention that information or items that it 16 designated for protection do not qualify for protection, that Designating Party must 17 promptly notify all other Parties that it is withdrawing the inapplicable designation. 18 7.2 Manner and Timing of Designations. Except as otherwise provided in 19 this Order (see, e.g., second paragraph of section 7.2(a) below), or as otherwise 20 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection 21 under this Order must be clearly so designated before the material is disclosed or 22 produced. 23 Designation in conformity with this Order requires: 24 (a) for information in documentary form (e.g., paper or electronic 25 documents, but excluding transcripts of depositions or other pretrial or trial 26 proceedings), that the Producing Party affix at a minimum, the legend 27 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 1 protection, the Producing Party also must clearly identify the protected portion(s) 2 (e.g., by making appropriate markings in the margins). 3 A Party or Non-Party that makes original documents available for inspection 4 need not designate them for protection until after the inspecting Party has indicated 5 which documents it would like copied and produced. During the inspection and before 6 the designation, all of the materials made available for inspection shall be deemed 7 “CONFIDENTIAL.” After the inspecting Party has identified the documents it wants 8 copied and produced, the Producing Party must determine which documents, or 9 portions thereof, qualify for protection under this Order. Then, before producing the 10 specified documents, the Producing Party must affix the “CONFIDENTIAL legend” 11 to each page that contains Protected Material. If only a portion of the material on a 12 page 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 (b) for testimony given in depositions that the Designating Party identifies 15 the Disclosure or Discovery Material on the record, and before the close of the 16 deposition all protected testimony. 17 (c) for information produced in some form other than documentary and for 18 any other tangible items, that the Producing Party affix in a prominent place on the 19 exterior of the container or containers in which the information is stored the legend 20 “CONFIDENTIAL.” If only a portion or portions of the information warrants 21 protection, the Producing Party, to the extent practicable, shall identify the protected 22 portion(s). 23 7.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 24 failure to designate qualified information or items does not, standing alone, waive the 25 Designating Party’s right to secure protection under this Order for such material. 26 Upon timely correction of a designation, the Receiving Party must make reasonable 27 efforts to assure that the material is treated in accordance with the provisions of this 1 VIII. CHALLENGING CONFIDENTIALITY DESIGNATIONS 2 8.1 Timing of Challenges. Any Party or Non-Party may challenge a 3 designation of confidentiality at any time that is consistent with the Court’s 4 Scheduling Order. 5 8.2 Meet and Confer. The Challenging Party shall initiate the meet and 6 confer process outlined in Local Rule 37.1, et seq. 7 8.3 The burden of persuasion, in any such challenge proceeding, shall be on 8 the Designating Party. Frivolous challenges, and those made for an improper purpose 9 (e.g., to harass or impose unnecessary expenses and burdens on other parties) may 10 expose the Challenging Party to sanctions. Unless the Designating Party has waived 11 or withdrawn the confidentiality designation, all parties shall continue to afford the 12 material in question the level of protection to which it is entitled under the Producing 13 Party’s designation until the Court rules on the challenge. 14 IX. ACCESS TO AND USE OF PROTECTED MATERIAL 15 9.1 Basic Principles. A Receiving Party may use Protected Material that is 16 disclosed or produced by another Party or by a Non-Party in connection with this 17 Action only for prosecuting, defending or attempting to settle this Action. Such 18 Protected Material may be disclosed only to the categories of persons and under the 19 conditions described in this Order. When the Action has been terminated, a Receiving 20 Party must comply with the provisions of Section VI, infra. 21 Protected Material must be stored and maintained by a Receiving Party at a 22 location and in a secure manner that ensures that access is limited to the persons 23 authorized under this Order. 24 9.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 25 otherwise ordered by the Court or permitted in writing by the Designating Party, a 26 Receiving Party may disclose any information or item designated 27 “CONFIDENTIAL” only to: 1 as employees of said General Counsel of Record to whom it is reasonably necessary 2 to disclose the information for this Action; 3 (b) the officers, directors, and employees (including House Counsel) of the 4 Receiving Party to whom disclosure is reasonably necessary for this Action; 5 (c) Experts (as defined in this Order) of the Receiving Party to whom 6 disclosure is reasonably necessary for this Action and who have signed the 7 “Acknowledgment and Agreement to Be Bound,” attached and hereafter referred to 8 as “Exhibit A.” 9 (d) the court and its personnel; 10 (e) court reporters and their staff; 11 (f) professional jury or trial consultants, mock jurors, and Professional 12 Vendors to whom disclosure is reasonably necessary for this Action and who have 13 signed Exhibit A. 14 (g) the author or recipient of a document containing the information or a 15 custodian or other person who otherwise possessed or knew the information; 16 (h) during their depositions, witnesses, and attorneys for witnesses, in the 17 Action to whom disclosure is reasonably necessary provided: (1) the deposing party 18 requests that the witness sign Exhibit A; and (2) they will not be permitted to keep 19 any confidential information unless they sign Exhibit A, unless otherwise agreed by 20 the Designating Party or ordered by the Court. Pages of transcribed deposition 21 testimony or exhibits to depositions that reveal Protected Material may be separately 22 bound by the court reporter and may not be disclosed to anyone except as permitted 23 under this Order; and 24 (i) any mediator or settlement officer, and their supporting personnel, 25 mutually agreed upon by any of the parties engaged in settlement discussions. 26 X. PROTECTED MATERIAL SUBPOENAED OR ORDERED 27 PRODUCED IN OTHER LITIGATION 1 that compels disclosure of any information or items designated in this Action as 2 “CONFIDENTIAL,” that Party must: 3 (a) promptly notify in writing the Designating Party. Such notification shall 4 include a copy of the subpoena or court order; 5 (b) promptly notify in writing the party who caused the subpoena or order to 6 issue in the other litigation that some or all of the material covered by the subpoena 7 or order is subject to this Order. Such notification shall include a copy of this Order; 8 and 9 (c) cooperate with respect to all reasonable procedures sought to be pursued 10 by the Designating Party whose Protected Material may be affected. 11 If the Designating Party timely seeks a protective order, the Party served with 12 the subpoena or court order shall not produce any information designated in this action 13 as “CONFIDENTIAL” before a determination by the Court from which the subpoena 14 or order issued, unless the Party has obtained the Designating Party’s permission. The 15 Designating Party shall bear the burden and expense of seeking protection in that court 16 of its confidential material and nothing in these provisions should be construed as 17 authorizing or encouraging a Receiving Party in this Action to disobey a lawful 18 directive from another court. 19 XI. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE 20 PRODUCED IN THIS LITIGATION 21 (a) The terms of this Order are applicable to information produced by a Non- 22 Party in this Action and designated as “CONFIDENTIAL.” Such information 23 produced by Non-Parties in connection with this litigation is protected by the 24 remedies and relief provided by this Order. Nothing in these provisions should be 25 construed as prohibiting a Non-Party from seeking additional protections. 26 (b) In the event that a Party is required, by a valid discovery request, to 27 produce a Non-Party’s confidential information in its possession, and the Party is 1 confidential information, then the Party shall: 2 (1) promptly notify in writing the Requesting Party and the Non-Party 3 that some or all of the information requested is subject to a confidentiality agreement 4 with a Non-Party; 5 (2) promptly provide the Non-Party with a copy of this Order in this 6 Action, the relevant discovery request(s), and a reasonably specific description of the 7 information requested; and 8 (3) make the information requested available for inspection by the Non- 9 Party, if requested. 10 (c) If the Non-Party fails to seek a protective order from this Court within 11 fourteen (14) days of receiving the notice and accompanying information, the 12 Receiving Party may produce the Non-Party’s confidential information responsive to 13 the discovery request. If the Non-Party timely seeks a protective order, the Receiving 14 Party shall not produce any information in its possession or control that is subject to 15 the confidentiality agreement with the Non-Party before a determination by the Court. 16 Absent a court order to the contrary, the Non-Party shall bear the burden and expense 17 of seeking protection in this Court of its Protected Material. 18 XII. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 19 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 20 Protected Material to any person or in any circumstance not authorized under this 21 Order, the Receiving Party must immediately (a) notify in writing the Designating 22 Party of the unauthorized disclosures; (b) use its best efforts to retrieve all 23 unauthorized copies of the Protected Material; (c) inform the person or persons to 24 whom unauthorized disclosures were made of all the terms of this Order; and (d) 25 request such person or persons to execute Exhibit A. 26 XIII. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 27 PROTECTED MATERIAL 1 inadvertently produced material is subject to a claim of privilege or other protection, 2 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 3 Procedure 26(b)(5)(B). This provision is not intended to modify whatever procedure 4 may be established in an e-discovery order that provides for production without prior 5 privilege review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the 6 Parties reach an agreement on the effect of disclosure of a communication or 7 information covered by the attorney-client privilege or work product protection, the 8 Parties may incorporate their agreement in a subsequent stipulation to the Court. 9 XIV. MISCELLANEOUS 10 14.1 Right to Further Relief. Nothing in this Order abridges the right of any 11 person to seek its modification by the Court in the future. 12 14.2 Right to Assert Other Objections. By stipulating to the entry of this 13 Order, no Party waives any right it otherwise would have to object to disclosing or 14 producing any information or item on any ground not addressed in this Order. 15 Similarly, no Party waives any right to object on any ground to use in evidence of any 16 of the material covered by this Order. 17 14.3 Filing Protected Material. A Party that seeks to file under seal any 18 Protected Material must comply with Local Civil Rule 79-5. Protected Material may 19 only be filed under seal pursuant to a court order authorizing the sealing of the specific 20 Protected Material at issue. If a Party’s request to file Protected Material under seal 21 is denied by the Court, then the Receiving Party may file the information in the public 22 record unless otherwise instructed by the Court. 23 XV. FINAL DISPOSITION 24 After the final disposition of this Action, as defined in Section VI, supra, within 25 60 days of a written request by the Designating Party, each Receiving Party must 26 return all Protected Material to the Producing Party or destroy such material. As used 27 in this subdivision, “all Protected Material” includes all copies, abstracts, 1 Protected Material. Whether the Protected Material is returned or destroyed, the 2 Receiving Party must submit a written certification to the Producing Party (and, if not 3 the same person or entity, to the Designating Party) by the 60 day deadline that (1) 4 identifies (by category, where appropriate) all the Protected Material that was returned 5 or destroyed and (2) affirms that the Receiving Party has not retained any copies, 6 abstracts, compilations, summaries or any other format reproducing or capturing any 7 of the Protected Material. Notwithstanding this provision, Counsel are entitled to 8 retain an archival copy of all pleadings, motion papers, trial, deposition, and hearing 9 transcripts, legal memoranda, correspondence, deposition and trial exhibits, expert 10 reports, attorney work product, and consultant and expert work product, even if such 11 materials contain Protected Material. Any such archival copies that contain or 12 constitute Protected Material remain subject to this Order as set forth in Section VI, 13 supra. 14 / / / 15 / / / 16 / / / 17 / / / 18 / / / 19 / / / 20 / / / 21 / / / 22 / / / 23 / / / 24 / / / 25 / / / 26 / / / 27 / / / 1) XVI. VIOLATION 2 Any violation of this Order may be punished by appropriate measures 3 □□ including, without limitation, contempt proceedings and/or monetary sanctions. || DATED: June 25, 2025 ROBERT STANFORD BROWN, APC 5 6 /s/ Robert S. Brown 7 By: ROBERT S. BROWN 8 Attorneys for Plaintiff SADE 9 THOMPSON 10 || DATED: June 25, 2025 HURRELL CANTRALL LLP 11 sz (12 328 43 By: /s/ Jordan S. Stern THOMAS C. HURRELL pee 14 JORDAN S. STERN gus 15 Attorneys for Defendants COUNTY OF LOS ANGELES, YADIRA vg" 16 CERVANTES, SGT. OSCAR MEDINA 17 and SGT. OGUNJUMO 18 19 FOR GOOD CAUSE SHOWN, IT IS SO ORDERED.

20 21 DATED: June 26, 2025 22 23 24 Hon. Stephanie S. Christensen 25 United States Magistrate Judge 26 27 28

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 5 penalty of perjury that I have read in its entirety and understand the Stipulated 6 Protective Order that was issued by the United States District Court for the Central 7 District of California in the case of Sade Thompson v. County of Los Angeles, et al. 8 USDC Case No.: 2:24-cv-10252-SRM-SSCx. I agree to comply with and to be bound 9 by all the terms of this Stipulated Protective Order and I understand and acknowledge 10 that failure to so comply could expose me to sanctions and punishment in the nature 11 of 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 or 13 entity except in strict compliance with the provisions of this Order. I further agree to 14 submit to the jurisdiction of the United States District Court for the Central District 15 of California for enforcing the terms of this Stipulated Protective Order, even if such 16 enforcement proceedings occur after termination of this action. 17 18 Date: _________________________________ 19 20 City and State where sworn and signed: _________________________________ 21 22 Printed name: _________________________________ 23 24 Signature: _________________________________ 25 26 27