Subpoena for Chang M. Park 2020CITY OF
CUPERTINO
OFFICE OF THE CITY CLERK
CITY HALL
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
TELEPHONE: (408) 777-3223 - FAX: (408) 777-3366
CUPERTINO.ORG
December 14, 2020
U.S. Legal Support, Inc.
20970 Warner Center Lane, Suite C
Woodland Hills, CA 91367
westrecords@uslegalsupport.com
Re:
Case:
Case No:
Deposition Subpoena for Production of Business Records, WorkOrder#: 315480.001
Park v Lin, et al.
20CV370284
To Whom It May Concern:
Below is the total amount due for compiling records, staff time, and shipping. Please remit the amount
of $24.00 by calling (408) 777-3220 to make payment by credit card over the phone or make a check
payable to City of Cupertino and mail to 10300 Torre Avenue, Cupertino, CA 95014 Kirsten Squarcia,
City Clerk. If you have any questions or concerns, contact our office at (408) 777-3223.
Prices Total
Staff time-1 hour $24.00/hour $24.00
Subtotal $24.00
Deposit -$15.00
Total $9.00
Sincerely,
Kirsten Squarcia
City Clerk
U.S. Legal Support, Inc.
20970 Warner Center Lane, Suite C
Woodland Hills, CA 91367
Phone: (818) 878-9227 / E-Mail: westrecords@usJegalsupport.com
WorkOrder #:315480.001
Access Code: 1632283
Due Inte: 12/14/2020 9:00AM
NOnCE TO PARTIES BEING SUBPOENAED
TO THE CUSTODIAN OF RECORDS OF:
Cupertino City Hall
10300 Torre Avenue
Cupeitino, CA 95014
ECEUVE
RECORDS REGARDING:
Chang M. Park
DOB:
CUPERTINO CiTY CLERK
SSN: UNKNOWN
l) Remember to sign the enclosed Declaration of Custodian of Records form
2) Please include our work order number 315480.001, on all correspondence.
3) If radiological films are requested, a complete list of breakdown is required prior to
production of films.
You may satisfy the provisions of this stbpoena by con'iplying witli any one of the following instructions:
Upload the records to HTTPS//MEDREC.USLEGALSUPP(RT.COM by entering tl'ie Work
Order Number and Access Code listed on tlie upper right liaiid corner of tliis document.
E-Mail the records securely to westrecords@,uslegalsuppoit.com
Mail your response to orir attention, taking the following steps:
a.
b.
C.
d.
Copy tlie requested records (or duplicate tlie requested items or materials). If no such
records or materials, go to step c.
Contact U.S. LEGAL SUPPORT prior to sending tlie records if there are any additional
fees for producing the records or n'iaterials.
Complete tlie declaration form(the last page in tlie subpoena packet sent to you) to
indicat6 tl'ie records and/or items being sent, or to indicate that you have none of the
records and/or requested if tliey do not exist.
Mail records to: US Legal Support, 20970 Warner Center Lane, Suite C, Woodland Hills,
CA 91367. Please make sure to include our reference number (found in tlie upper right
hand corner of tliis notice) on all correspondence you send.
IF YOU HAVE ANY QUESTIONS REG ARDING THE ATT ACHED SUBPOENA OR HOW TO RESPOND,
PLEASE FEEL FREE TO GIVE US A CALL, (818) 878-9227.
WOrkOrder #: 31 54Rn nnlATTORNEY OR PARTY WITHOUT ATTORNEY lNBme. }late biil nllmbaTl and nddlgss):
Welland Chiang, Esquire, SBN: 309188
Stratman, Schwartz & Williams-Abrego - Oakland
505 14(h Street, Sulte 400
Oakland, CA 94612
TELEPHONE: (!510) 457-3440 FAXNO.I (5"lO) 238-8968
ATI'ORNEY FOR (name) Defendants Ltn, et al.
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
STREET ADDRESS: 191 NORTH FIRST STREET
MAILING ADDRESS: 191 NORTH FIRST STREET
CITY AND ZIP CODE: SAN JOSE, 95113
BRANCH NAME: DOWNTOWN
PLAINTIFF/PETITIONER: Park
DEFENDANT/RESPONDENT: Lln, et al.
CASE NUMBER:
20CV370284
NOTICE TO CONSUMER OR EMPLOYEE AND OBJECTION
(Code of Civ. Proc., §§ 1985.3, '1985.6)
NOTICE TO CONSUMER OR EMPLOYEE
TO (name): Chang M. Park
1. PLEASE TAKE NOTICE THAT REQUESTING PARTY (name): Lin, et al.
SEEKS YOLIR RECORDS FOR EXAMINATION by the parties to this action on (Specify Date): 12/"14/2020 9:00AM
The records are described in the subpoena directed to witness (specify name and address of person or entity from whom records are sought}:Cupertino City Hall, 10300 Torre Avenue, Cupertino, CA 95014
A copy of the subpoena is attached.
2. If you object to the production of these records, YOU MUST DO ONE OF THE FOLLOWING BEFORE THE DATE SPECIFIED INITEM a. OR b. BELOW:
a. If you are a party to the above-entitled action, you must file a motion pursuant to Code of Civil Procedure section 1987.1 toquash or modify the subpoena and give notice of that motion to the witness and the deposition officer named in thesubpoena at least five days before the date set for the production of the records.
b. If you are not a party to this action, you must serve on the requesting party and on the witness, before the date set forproduction of the records, a written objection that states the specific grounds on which production of such records should beprohibited. You may use the form below to object and state the ground for your objection. You must coi'nplete the Proof ofService on the reverse side indicating whether you personally served or mailed the objection. The objection should not befiled with the court. WARNING: IF YOUR OBJECTION IS NOT RECEIVED BEFORE THE DATE SPECIFIED IN ITEM 1,YOUR RECORDS MAY BE PRODUCED AND MAY BE AVAILABLE TO ALL PARTIES.
3. YOUORYOURATTORNEYMAYCONTACTTHEUNDERSIGNEDtodeterminewhetheranagreementcanbereachedinwritingto
cancel or limit the scope of the subpoena. If no such agreement is reached, and if you are not other wise represented by an attorney inthis action, YOU SHOULD CONSULT AN ATTORNEY TO ADVISE YOU OF YOLIR RIGHTS OF PRIVACY.
Date: 11/10/2020
Weiland Chiang, Esquire
(TYPE OF PRINT NAMEI
/S/ Weiland Chiang, Esquire
(SIGNATtlREOF[] REQUESTINGPARTY EX ATTORNEY)
OBJECTION BY NON-PARTY TO PRODUCTION OF RECORDS
1. 01 object to the production of all of my records specified in the subpoena.
2, [11 object only to the production of the following specified records:
3. The specific grounds for my objection are as follows:
Date:
ITfPE OF PRINT NAME)SIGNATURE OF REOuESTING PARTY ATTORNEY
(Proof of sennce on page 2)
Form Adopted kn Mandglo7 llm
Jiidlclal Coiincll of Calllotnla NOTICE TO CONSllMF.R OR li:A'lPLOYEE AND OB.JECTJON Code of CMI Piocedtue.
1§1985 3. 1985 6
WorkOrriprtt Al !'izlFln nr I
PLAINTIFF/PETITIONER Park
DEFENDANT/RESPONDENT: Lin, et al.
CASE NUMBER:
20CV370284
PROOF OF SERVICE OF NOTICE TO CONSUMER OR EMPLOYEE AND OBJECTION
(Code Civ. Proc.,§§ 1985.3, 1985.6)
[2]Personal Service 8 Mail
1. At this time of service I was at least 18 years of age and not a party to this legal action.
2. I served a copy ofthe Notice to ConsumerorEmployee and Objection as follows (check either a or b):
a. € Personal service. I personally delivered the Notice to Consumer or Employee and Objection as follows,
(1) Name of person served: (3) Date served:
(2) Address: (4)Timeserved:
b. U] Mail. I deposited the Notice to ConsumerorEmptoyee and Objection in the United States mail, in a sealed envelope with
postage fully prepaid. The envelope was addressed as follows:
(1 ) Name of person served: SEE ATTACHED SERVICE LIST (3) Date of mailing: 1 1/1 0/2020
(2) Address: (4) Place of mailing: Woodland Hills, CA
(5) I am a resident of or employed in the county where the Notice of Consurr'ierarEmployee and Objection was mailed.
c. My residence or business address is (specify): 20970 Warner Center Ln. Suite C, Woodland Hills, CA 9138z
d. My phone number is (specify): (818) 878-9227
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date: 11/10/2020
Angie Salvatierra
(TYPE OR PRINT NAME OF PERSON WHO SERVED)iSIGNATuRE OF PERSON WHO SERVED)
PROOF OF SERVICE OF OBJECTION TO PRODUCTION OF RECORDS
COPDeErsOoFnaCllsVe.rPvRlcOeC., kM98a51l.3, 1985.6
L At this time of service I was at least 18 year of age and not a party to this legal action.
2. I served a copy of the Objections to Production of Records as follow (complete either a or b)
a. ON THE REQUESTING PARTY
(1 ) 0 Personal service. I personally delivered the Objection to Production of Records as follows:
(i) Name of person served: (iii) Date served:
(ii)Address: (iv)Timeserved:
(2.) 0 Mail. I deposited the Objection to Production of Records in the United Stated mail, in a sealed envelope with
postage fully prepaid. The envelope was addressed as follows:
(i) Name of person served: (iii) Date served:
(ii)Address: (iv)Timeserved:
(v) I am resident of or employed in the county where the Objection to Production of Records was mailed.
b. ON THE WITNESS:
(1 ) [3 Personal service. I personally delivered the Objection to Production of Records as follows:
(i) Name of person served: (iii) Date served:
(ii)Address: (iv)Timeserved:
(2) 0 Mail. I deposited the Objection to Production of Records in the United Stated mail, in a sealed envelope with
postage fully prepaid. The envelope was addressed as follows:
(i) Name of person served: (iii) Date served:
(ii)Address: (iv)Timeserved:
3. My residence or business address is: (specify)
4. My phone number is: (specify)
l declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF PERSON WHO SERVED)(SIGNATURE OF PERSON WHO SERVED)
Page 2 of 2
Foim Adiipled loi Mandnk llsa
Judlcial Council or CallTornla NOTICE TO CONStlME1l OR EMPLOYEE AND OBJECTION Codti at CMI Piocaduni.
I ) 1985 3. l 985 6.
Patak,
YS.
Lin, et al.,
Case No.: 20CV370284
SERVICE LIST
Abid Aziz, Esquire
Aziz Yellin LLP
996 Mtnnesota Avenue, Suite 204
San Jose, CA 95125
(406)203-4627 Fax: N/A
WorkOrder# 315480
WOrkOrtm# :ll!idRn nM
An08NEY OR PARTY WITHOUT A'nORNEY (Name, stale bar numbst. and adtkers)
Weiland Chiang, Esquire, SBN: 309188
8tratman, Schwartz & Williams-Abrego - Oakland
50514th Street, Suite 400
Oakland, CA 946al2
TELEPHONE NO.. (510) 457-3440 FAX (510) 238-8968
ATTORNEY FOR (NAME)I Defendants Lin, et al.
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
STREET ADDRESS: 19al NORTH FIRST STREET
MAILING ADDRESS: 191 NORTH FIRST STREET
CITY AND ZIP CODE: SAN JOSE, CA 95113
BRANCH NAME: DOWNTOWN
PLAINTIFF/PETITIONER:Park
DEFENDANT/RESPONDENT:Lin, et al.
DEPOSITION SUBPOENA
FOR PRODUCTION OF BUSINESS RECORDS
CASE NUMBER:
20CV370284
rHE PEOPLE OF THE STATE OF CALIFORNIA, TO: The Custodian of Records for:
Cupertino City Hall
10300 Torre Avenue, Cupertino, CA 950'l4
1. YOU ARE ORDERED TO PRODLICE THE BUSINESS RECORDS described in item 3. as follows:
TO (name ofdeposition office): u.s. Legal Support, Inc.
ON (date)/ AT (time): 12/14/2020 9:00AM
LOCATION: 20970 Warner Center Ln. Suite C, Woodland Hills, CA 91367
I Do not release the requested records to the deposition officer prior to the date and time stated above. l
fJa. by delivering a true, legible and durable copy of business records described in item 3, enclosed in a sealed innerwrapper with the title and number of the action, name of witness, and date of subpoena clearly written on it. The inner wrapper
shall then be enclosed in an outer envelope or wrapper, sealed, and mailed to the deposition officer at the address in Item 1.
€b. by delivering a true, legible and durable copy of the business records described in item 3 to the deposition officer at
the witness's address, on receipt of payment in cash or by check of the reasonable costs of preparing the copy, as determined
under Evidence Code Section 1 563(b).
c.[x by making the original business records described in item 3 available for inspection at your business address by the
attorney's representative and permitting copying at your business address under reasonable conditions during normal
business hours.
2. The records are to be produced by the date and time shown in item 1 (but not sooner than 20 days after the issuance of the
deposition subpoena, or 15 days after service, whichever date is later). Reasonable costs of locating records, making them available
or copying them, and postage, if any, are recoverable as set forth in Evidence Code section 1563(b). The records shall be
accompanied by an affidavit of the custodian or other qualified w/tness pursuant to Evidence Code Section 1561.
3. The records to be produced are described as follows (if electronically stored information is demanded, the form or forms in
which each type of information is to be produced may be specified) :
Any and all records and documents pertaining to notice violations and / or inspections in 20895 Jollyman Dr. Cupertino, CA 95014.
gContinued on Attachment 3.
4. IF YOU HAVE BEEN SERVED WITH THIS SuBPOENA AS A CUSTODIAN OF CONSUMER OR EMPLOYEE RECORDS UNDER CODE OF
CIVIL PROCEDURE SECTION 1985.3 0R 1985.6 AND A MOTION TO QUASH OR AN OBJECTION HAS BEEN SERVED ON YOU, A COURT
ORDER OR AGREEMENT OF THE PARTIES, WITNESSES, AND CONSUMER OR EMPLOYEE AFFECTED MUST BE OBT AINED BEFORE
YOU ARE REQUIRED TO PRODUCE CONSUMER OR EMPLOYEE RECORDS.
DISOBEDIENCE OF THIS SUBPOENA MAY BE PUNISHED AS CONTEMPT BY THIS COURT. YOU WILL ALSO BE LIABLE
FOR THE SUM OF FIVE HUNDRED DOLLARS AND ALL DAMAGES RESULTING FROM YOUR FAILURE TO OBEY
Dateissued: 11/10/2020
Weiland Chiang, Esquire
iTYPE OR PRINT NAME)
/S/Weiland Chiang, Esquire
(SIGNATURE OR PERSON ISSUING SUBPOENA)
ATTORNEY -AT-LAW
(TITLE)
%im Adaplad for )ilandalay Ute
Judldal Coundl oT Calltomia
8uBPOt(1 l)Tav. Jnnuarl I. 2(1121
(Proof of service on reverse)
DEPOSITION SUBPOENA FOR PRODUCTION
OFBUSINESS RECORDS
Page j o[ 2
Code of Clvil Ptocedute. 4!i 2020 410 - 2020.440.
Govemmenl Dida.§ 680'l7 I
WorkOrder#: 3"l5480.001
PLANTIFF/PETITIONER: Park
DEFENDANT/RESPONDENT: Lin, et al.
CASE NUMBER:
20CV370284
PROOF OF SERVICE OF DEPOSITION SUBPOENA FOR
PRODUCTION OF BUSINESS RECORDS
1. I served this Deposition Subpoena for Production of Business Records by personally delivering a copy to the person served asfollows:
a. Person served (name):
' Address Where se"ed: Cupeitino City Hall, 10300 Torre Avenue
Cupertino, CA 95014
Phone: 408-777-3200
c. Date of delivery :
d. Time of delivery:
a. (1)€ Witnessfeeswerepaid.
Amount................... $
(2) [1] Copying fees were paid.
Amount................... $
f. Fee for service...................... $
2. I received this subpoena for service on : (date)
3. Person serving:
a. 0 Not a registered California process server.
b. [2 California sheriff, marshal, or constable.
c. [2 Registered California process server.
d. 0 Employee or independent contractor of a registered California process server.
e. [3 Exempt from registration under Bus. & Prof. Code section 22350(b).
f. [x Registered professional photocopier.
g. [1] Exempt from registration under Bus. & Prof. Code section 22451.
h. Name, address, and telephone number, and if applicable, county of registration and number:
u.s. Legal Support, Inc.
20970 Warner Center Ln. Suite C
Woodland Hills, CA 91367
Phone: (818) 878-9227
I declare under penalty of perlury under the laws of the State of
California that the foregoing is true and correct.
Date:
(For California sheriff or marshal use only)
I certify that the foregoing is true and correct.
Date:
iSIGNATURE)(SIGNATURE)
6UBPl)1011m ltnutty I. }0121 DEPOSITION SUBPOENA FOR PRODUCTION
OF BUSINESS RECORDS
Page2 of
U.S. Legal Support, Inc.
20970 Wai'i'ier Center Lane, Stiite C
Woodland Hills, CA 91367
Phone: (818) 878-9227 FAX: (818) 878-9851 E-Mail: westrecords@uslegalsuppoit.coi'n
WorkOrder#: 315480.001
CSR: Debra Muriiietta
Records On: Cliang M. Park DOB: SSN: U?%lKNOWN
Location: Cupeitino City Hall
1. DECLARATION OF CUSTODIAN OF RECORDS
Ibeing the duly authorized custodian of records and liaving t}ie authority to certify tlie records, declare the following:
A. Description of Records Produced (REQUIRED):
[ ] Medical Records [ ] Billing Records [ ] X-Rays [] Otlier:
The records indicated below were requested, but do not exist:
[ ] Medical Records [ ] Billing Records [ ] X-Rays [ ] Otl'ier:
Code Enforcement Records
Tlie records were prepared by the personnel of the business in the ordinary course of business at or near the time of the act,
condition, or event.
B. In wliat manner ivere the records produced (REQUIRED):
[x] Data/Coinputer Generated [x] Typed/Hand Written Notes [ ] Summaiy [ ] Radiological
[ ] Audio/Video [ ] Patliological [ ] Otlier:
C. Certiflcation of Records Copied or Obtained: (REQUIRED)
[X] The copy is a true copy of all the records described in the subpoena duces tecuin or searcli warrant, or pursuant to
subdivision (e) of Section 1560, the records were delivered to the attorney, tlie attorney's representative, or deposition officer for
copying at the custodian's or wihiess' place of business, as the case iiiay be.
2, CERTIFICATION OF NO RECORDS
[ ] A tltorough searcli of our files, carried out under my direction revealed no docuinents,
records or other inaterial called for in tlie Stibpoena or Autliorization searclied by Naine, SSN, DOB, etc.
[ ] Existing records not within tlie time lii'nitation set foitli in tlie request.
[ ] All records have been destroyed in accordance witli our docuinent retention policy whicli is eai's.
[ ] The following infon'nation does not match wliat we liave [ ]DOB [ ]SSN [ ]NAME [ ]Otlier
[ ] Additiona) infonnation is needed sticli as:
[ ] Otlier explanation:
3. Under pei'ialty of perjury and under the laws of California, I the CUSTODIAN of RECORDS, declare tliat tlie foregoing is true
and correct.
cUSTODIANSIGNATUREpDrailnet:nalm2e/lK4i/r2sotenSqaarCiaC"CuPseigrn'ejna:o'CA
, California
(OFFICE USEONLY) CERTIFICATIONOF PROFESSIONAL PHOTOCOPIER
I, tlie undersigned, declare under penalty of peijuiy tliat tlie foregoing is h'tie and coi'rect:
Executed on , California
Print Naine Signed
State of California
EVIDENCE CODE
Section 1561
1561. (a) The records sliall be accoinpai'iied by tlie afidavit of tlie custodian or otl'ier qualified witness, stating in stibstance eacli of tlie
followii'ig:
(l) Theaffiantisthedulyauthorizedcustodianoftherecordsorotherqualifiedwitnessandliasaut)ioritytoceitifytlierecords.
(2) The copy is a true copy of all tlie records described in tlie subpoena duces tecum or search wai'rant, or ptirstiant to stibdivision (e)
of Section 1560, tlie records were delivered to tlie attoi'ney, tlie attorney's 'representative, or deposition officer for copyii'ig at tlie custodiai'i's
or witness' place of business, as the case may be.
(3) The records were prepared by the personnel of the business in tlie ordinary course of business at or near tl'ie tiine of tlie act,
condition, or event.
(4) Tlie identity of tlie records.
(5) A description of t)ie mode of preparation of tlie records.
(b) [f the business lias none of tl'ie records described, or only patt thereof, the custodian or otlier qualified witness sliall so state in tlie
affidavit, and deliver the affidavit and tliose records tliat are available in one of tlie manners provided in Section 1560,
(c) If the records described in the subpoena were delivered to the attorney or liis or her representative or deposition officer for copying
at tl'ie ctistodian's or witness' p!ace of business, in addition to the affidavit required by subdiyision (a), tlie records sliall be accompanied by
an affidavit by tlie attoi'ney or his or her representative or deposition officer stating that t)ie copy is a tt'ue copy of all tlie records delivered to
tlie attorney or his or her representative or deposition officer for copying.
(Ainended by Stats. 2016, Cli. 85, Sec. 2. (SB 1087) Effective.+anuary 1, 2017.)
11/24/2020 Print Your Documents
L1.S. Legal Support,Inc.
admin
20970 Wamet Center Ln. Suite C
WoodlandHills CA91367
USPS CERTIFIED M All-
lIllllIIllllIIllIlllllllllllllIIIllIIIIIllllIl
9414 8149 0160 5554 3660 74
Cupertino City Hall
Cupertino City Hall
10300 Torre Avenue
Cupertino, CA 95014
pbsvcprd01/sendsuite live/projects/image.aspx?pd=1
<> su.usp.Lpeogrtal
ANNOUNCING THE u.s. LEGAL SUPPORT
MEDREC PORTAL
A fast and secure way to send records to u.s. Legal Support.
STEP I
Go to the website - https://medrec.usLegaLsupport.con'i.
Log in using the order number and access code located on your request.
STEP 2
Click browse to seLect the file you wish to i.ipLoad. Files may be in any
format, but we recommend zipping large files.
NOTE: You have the option to have enter an emaiL address to
receive confirmation when your file has been received.
STEP 3
Using the drop down provided, select the type of fiLe you have uploaded
and hit submit and confirm the submission. You will receive a message
indicating the upload was successful.
,'.
Recaid upload Portal
tr.s. Legal Support, Inc.
20970 Warner Centei- Lane, Suite C
Woodland Hills, CA 91367
Phone: (818)878-9227 FAX: (818)878-9851 E-Mail:westrecords@)uslegalsuppoit.coin
Records On: Cliang M. Park DOB: SSN: UNKNOWN
Location: Cupertino City Hall
WoAOrder#: 315480.001
CSR: Debra i'vlurrietta
1. DECL,RAT[ON OF CUSTODIAN OF RECORDS
I being the duly authorized custodian of records and having the autliority to certify tlie records, declare the following:
A. Description of Records Produced (REQUIRED):
[ ] Medical Records [ ] Billing Records [ ] X-Rays g] Otl'ier:
The records indicated below were requested, but do not exist:
[ ] Medical Records [ ] Billing Records [ ] X-Rays [ ] Otlier:
Code Enforcement Records
The records were prepared by the personnel of the business in the ordinary course of business at or near tlie time of tlie act,
condition, or event.
B. In what manner were tlie records produced (REQUIRED):
[)Cl Data/Computer Generated [X] Typed/Hand Written Notes [ ] Summaiy [ ] Radiological
[ ] Audio/Video [ ] Patliological [ ] Otlier:
C. Certification of Records Copied or Obtained: (REQUIRED)
(zl The copy is a true copy of all the records described in the stibpoena dttces tecum or searcli wai'rant, or ptirsuant to
subdivision (e) of Section 1560, the records were delivered to the attot'ney, the attorney's representative, or deposition officer for
copying at tlie custodian's or witness' place of business, as the case may be.
2. CERTIFICATION OF NO RECORDS
[ ] A tliorough searcli of our files, carried otit tinder my direction revealed no docui'nents,
records or other material called for in the Subpoena or Authorization searched by Name, SSN, DOB, etc.
[ ] Existing records not witliin tlie time lii'nitation set forth in tlie reqtiest.
[ ] All records have been destroyed in accordance with our document retentioi'i policy which is years.
[ ] Tlie following information does not match what we have [ ]DOB [ ]SSN [ ]NAME [ ]Otlier
[ ] Additional infoimation is needed such as:
[ ] Otlier explanation:
3. Under penalty of perjury and under the laws of California,Jthe CUSTODIAN or RECORDS, declare that tlie foregoing is true
and correct.
cUSTODIANslGNATUREDpraiIne(:(lalm2B/lp4a/u2i0oosuuivan
Citv
(OFFICE USE ONL}:) CERTlFICATiON OF PROFESSION,4L PHOTOCOPIER
I, tlie undersigned, declare under penalty of petjut'y that the foregoing is mte and cot'rect:
Exectited on , California
Print Naine Si,gned