Declaration if Custodian of Records - 10070 Imperial Ave. Cupertino, CA 95014WO-683467 Records Subject: 10070 Imperial Date of Birth SSN:
REC-682379
DECLARATION OF CUSTODIAN OF RECORDS
Name of records subject: 10070 Imperial Avenue, Cupertino,CA 95014
1 declare as follows pursuant to California Evidence Code sections 1560, 1561:
1 am employed by and am the duly authorized custodian of records and am authorized to certify records for:
CITY OF CUPERTINO CITY CLERK
(Facility Name)
Please be sure to include this Declaration along with the records you are providing to Gemini. Without a
completed Declaration, this Civil Subpoena has not been fulfilled. If no records are being provided to Gemini,
this Declaration is still required.
I certify (Please check all that apply):
F,71VN
That the accompanying records are true and complete copies of records described in the Civil Subpoena,
These records were maintained in the regular course and scope of business of the employer stated above and
were prepared by authorized personnel. No records, documents or other materials have been withheld except
as noted below. I further certify that I have made a diligent, thorough, and complete search of all available
sources including the computer databases for both open and closed files whether in-house or in a storage
facility or any other location under the control of my employer for any and all items to be produced on the
attached subpoena duces tecum or authorization for records subject named above.
That no records were produced because no records were found for the individual named on the subpoena
duces tecum. Please indicate the reason, if any, as to why records do not exist:
That partial records were produced. Please indicate below which records were not provided from those
requested on the attached Civil Subpoena:
F_JThat all or partial records are located at the following facility:
Facility Name, Address, and Phone Number:
Type of Records Located at this Facility
That records were provided to the Applicant Attorney of the Workers' Compensation case stated on the
provided subpoena daces tecum on (date).
Records were produced in the following manner:
Records were made available to Gemini and/or its affiliate for copying and/or picking up.
Q, Records were mailed/faxed/e-mailed to Gemini at the address listed on the Civil Subpoena in compliance
with Evidence Code section 1560.
I declare under penalty of perjury under the laws of the. State of California that the foregoing is true and
correct and that this Declaration is executed on 2.12-7* at �rL I n1 (city), State of C— .
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Printed name required Signature of custodian required
.� E M I IN 1 6020 West Oaks Blvd, Suite 310 • Rocklin, CA 95765
g-ii i n, du p I (oi i (,n. cow Phone.(877) 739-7481 • Fax (707) 204-6527
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