1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA – WESTERN DIVISION 10 11 HYACINTH LIVINGSTON, an Case No.: 2:21-cv-04027-AB (Ex) individual, (Los Angeles County Superior Court 12 Plaintiff, Case No.: 20STCV19299) 13 v. [Assigned to Hon. Andre Birotte, 14 Jr., District Judge; and Hon. Charles LOWE’S HOME CENTERS, LLC, a F. Eick, Magistrate Judge] 15 Limited Liability Company; LOWE’S COMPANIES, INC.; DOE PROTECTIVE ORDER 16 MANAGER 1 and DOES 1 to 30, Inclusive, [DISCOVERY MATTER: Referred 17 to Magistrate Judge Charles F. Eick] Defendants. 18 Complaint Filed: May 20, 2020 19 20 21 1. A. PURPOSES AND LIMITATIONS 22 Discovery in this action is likely to involve production of confidential, 23 proprietary, or private information for which special protection from public 24 disclosure and from use for any purpose other than prosecuting this litigation may 25 be warranted. Accordingly, the parties hereby stipulate to and petition the Court to 26 enter the following Stipulated Protective Order. The parties acknowledge that this 27 Order does not confer blanket protections on all disclosures or responses to 1 discovery and that the protection it affords from public disclosure and use extends 2 only to the limited information or items that are entitled to confidential treatment 3 under the applicable legal principles. The parties further acknowledge, as set forth 4 in Section 12.3, below, that this Stipulated Protective Order does not entitle them to 5 file confidential information under seal; Civil Local Rule 79-5 sets forth the 6 procedures that must be followed and the standards that will be applied when a party 7 seeks permission from the Court to file material under seal. 8 B. GOOD CAUSE STATEMENT 9 Federal Rules of Civil Procedure, Rule 26(c)(1) states in pertinent part, that 10 the Court, upon a showing of good cause may “issue an order to protect a party from 11 annoyance, embarrassment, oppression, or undue burden or expense.” Fed.R.Civ.P. 12 26(c)(1). In the instant matter, Defendant Lowe’s Home Centers, LLC’s 13 Confidential Documents contain proprietary and confidential trade secret 14 information relating to Defendant Lowe’s Home Centers, LLC’s business practices 15 and its safety protocol. Defendant Lowe’s Home Centers, LLC. (“Defendant” or 16 “Lowe’s”) derives independent economic value from maintaining the confidentiality 17 of the policies and procedures set forth in these Confidential Documents. 18 Defendant is a retailer in the home improvement industry and has conducted 19 business in California since 1998. The home improvement retail industry is very 20 competitive. As a result of years of investing time and money in research and 21 investigation, Defendant developed the policies contained in the Confidential 22 Documents for the purposes of maintaining the security and accessibility of its 23 merchandise, providing quality customer service, and ensuring the safety of its 24 employees and customers. These policies and procedures, as memorialized in the 25 Confidential Documents, were created and generated by Lowe’s for Lowe’s, and are 26 used for the purposes of maintaining safety at its stores and creating efficient and 27 organized work environments for its employees. As a result, Defendant is able to 1 minimize the waste of any resources, which is a key factor in generating profitability 2 for its business. 3 Defendant derives economic value from maintaining the secrecy of its 4 Confidential Documents. If disclosed to the public, the trade secret information 5 contained in Defendant’s Confidential Documents would reveal Defendant’s 6 internal operations and could potentially be used by competitors as a means to 7 compete for its customers, interfere with its business plans and thereby gain unfair 8 business advantages. If Defendant’s safety protocol were revealed to the general 9 public, it would hinder Defendant’s ability to effectively resolve and minimize 10 liability claims, and its goal of protecting its customers and employees from theft 11 and other crimes. Unrestricted or unprotected disclosure of such information would 12 result in prejudice or harm to Defendant by revealing Lowe’s competitive 13 confidential information, which has been developed at the expense of Lowe’s and 14 which represents valuable tangible and intangible assets. Accordingly, the parties 15 respectfully submit that there is good cause for the entry of this Protective Order. C. 16 ACKNOWLEDGMENT OF PROCEDURE FOR FILING UNDER SEAL 17 The parties further acknowledge, as set forth in Section 12.3, below, that this 18 Stipulated Protective Order does not entitle them to file confidential information 19 under seal; Local Civil Rule 79-5 sets forth the procedures that must be followed 20 and the standards that will be applied when a party seeks permission from the court 21 to file material under seal. 22 There is a strong presumption that the public has a right of access to judicial 23 proceedings and records in civil cases. In connection with non-dispositive motions, 24 good cause must be shown to support a filing under seal. See Kamakana v. City and 25 County of Honolulu,

(9th Cir. 2006), Phillips v. Gen. Motors 26 Corp.,

, 1210-11 (9th Cir. 2002), Makar-Welbon v. Sony Electrics, 27 Inc.,

(E.D. Wis. 1999) (even stipulated protective orders 1 require good cause showing), and a specific showing of good cause or compelling 2 reasons with proper evidentiary support and legal justification, must be made with 3 respect to Protected Material that a party seeks to file under seal. The parties’ mere 4 designation of Disclosure or Discovery Material as CONFIDENTIAL does not— 5 without the submission of competent evidence by declaration, establishing that the 6 material sought to be filed under seal qualifies as confidential, privileged, or 7 otherwise protectable—constitute good cause. 8 Further, if a party requests sealing related to a dispositive motion or trial, then 9 compelling reasons, not only good cause, for the sealing must be shown, and the 10 relief sought shall be narrowly tailored to serve the specific interest to be protected. 11 See Pintos v. Pacific Creditors Ass’n.,

(9th Cir. 2010). For 12 each item or type of information, document, or thing sought to be filed or introduced 13 under seal in connection with a dispositive motion or trial, the party seeking 14 protection must articulate compelling reasons, supported by specific facts and legal 15 justification, for the requested sealing order. Again, competent evidence supporting 16 the application to file documents under seal must be provided by declaration. Any 17 document that is not confidential, privileged, or otherwise protectable in its entirety 18 will not be filed under seal if the confidential portions can be redacted. If 19 documents can be redacted, then a redacted version for public viewing, omitting 20 only the confidential, privileged, or otherwise protectable portions of the document, 21 shall be filed. Any application that seeks to file documents under seal in their 22 entirety should include an explanation of why redaction is not feasible. 23 2. DEFINITIONS 24 2.1 Action: The instant action: Hyacinth Livingston v. Lowe’s Home 25 Centers, LLC, Case No: 2:21-cv-04027-AB (Ex). 26 2.2 Challenging Party: a Party or Non-Party that challenges the 27 designation of information or items under this Order. 1 2.3 “CONFIDENTIAL” Information or Items: information (regardless of 2 how it is generated, stored or maintained) or tangible things that qualify for 3 protection under Federal Rule of Civil Procedure 26(c), and as specified above in 4 the Good Cause Statement. 5 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as 6 their support staff). 7 2.5 Designating Party: a Party or Non-Party that designates information or 8 items that it produces in disclosures or in responses to discovery as 9 “CONFIDENTIAL.” 10 2.6 Disclosure or Discovery Material: all items or information, regardless 11 of the medium or manner in which it is generated, stored, or maintained (including, 12 among other things, testimony, transcripts, and tangible things), that are produced or 13 generated in disclosures or responses to discovery in this matter. 14 2.7 Expert: a person with specialized knowledge or experience in a matter 15 pertinent to the litigation who has been retained by a Party or its counsel to serve as 16 an expert witness or as a consultant in this Action. 17 2.8 House Counsel: attorneys who are employees of a party to this Action. 18 House Counsel does not include Outside Counsel of Record or any other outside 19 counsel. 20 2.9 Non-Party: any natural person, partnership, corporation, association, or 21 other legal entity not named as a Party to this action. 22 2.10 Outside Counsel of Record: attorneys who are not employees of a 23 party to this Action but are retained to represent or advise a party to this Action and 24 have appeared in this Action on behalf of that party or are affiliated with a law firm 25 which has appeared on behalf of that party, and includes support staff. 26 2.11 Party: any party to this Action, including all of its officers, directors, 27 employees, consultants, retained experts, and Outside Counsel of Record (and their 1 support staffs). 2 2.12 Producing Party: a Party or Non-Party that produces Disclosure or 3 Discovery Material in this Action. 4 2.13 Professional Vendors: persons or entities that provide litigation 5 support services (e.g., photocopying, videotaping, translating, preparing exhibits or 6 demonstrations, and organizing, storing, or retrieving data in any form or medium) 7 and their employees and subcontractors. 8 2.14 Protected Material: any Disclosure or Discovery Material that is 9 designated as “CONFIDENTIAL.” 10 2.15 Receiving Party: a Party that receives Disclosure or Discovery 11 Material from a Producing Party. 12 3. SCOPE 13 The protections conferred by this Stipulation and Order cover not only 14 Protected Material (as defined above), but also (1) any information copied or extracted 15 from Protected Material; (2) all copies, excerpts, summaries, or compilations of 16 Protected Material; and (3) any testimony, conversations, or presentations by Parties 17 or their Counsel that might reveal Protected 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 4. DURATION 21 Once a case proceeds to trial, information that was designated as 22 CONFIDENTIAL or maintained pursuant to this protective order used or introduced 23 as an exhibit at trial becomes public and will be presumptively available to all 24 members of the public, including the press, unless compelling reasons supported by 25 specific factual findings to proceed otherwise are made to the trial judge in advance 26 of the trial. See Kamakana,

(distinguishing “good cause” 27 showing for sealing documents produced in discovery from “compelling reasons” 1 standard when merits-related documents are part of court record). Accordingly, the 2 terms of this protective order do not extend beyond the commencement of the trial. 3 5. DESIGNATING PROTECTED MATERIAL 4 5.1 Exercise of Restraint and Care in Designating Material for Protection. 5 Each Party or Non-Party that designates information or items for protection under 6 this Order must take care to limit any such designation to specific material that 7 qualifies under the appropriate standards. The Designating Party must designate for 8 protection only those parts of material, documents, items or oral or written 9 communications that qualify so that other portions of the material, documents, items 10 or communications for which protection is not warranted are not swept unjustifiably 11 within the ambit of this Order. 12 Mass, indiscriminate or routinized designations are prohibited. Designations 13 that are shown to be clearly unjustified or that have been made for an improper 14 purpose (e.g., to unnecessarily encumber the case development process or to impose 15 unnecessary expenses and burdens on other parties) may expose the Designating 16 Party to sanctions. 17 If it comes to a Designating Party’s attention that information or items that it 18 designated for protection do not qualify for protection, that Designating Party must 19 promptly notify all other Parties that it is withdrawing the inapplicable designation. 20 5.2 Manner and Timing of Designations. Except as otherwise provided in 21 this Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise 22 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection 23 under this Order must be clearly so designated before the material is disclosed or 24 produced. 25 Designation in conformity with this Order requires: 26 (a) for information in documentary form (e.g., paper or electronic 27 documents, but excluding transcripts of depositions or other pretrial or trial 1 proceedings), that the Producing Party affix at a minimum, the legend 2 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 3 contains protected material. If only a portion of the material on a page qualifies for 4 protection, the Producing Party also must clearly identify the protected portion(s) 5 (e.g., by making appropriate markings in the margins). A Party or Non-Party that 6 makes original documents available for inspection need not designate them for 7 protection until after the inspecting Party has indicated which documents it would 8 like copied and produced. During the inspection and before the designation, all of 9 the material made available for inspection shall be deemed “CONFIDENTIAL.” 10 After the inspecting Party has identified the documents it wants copied and 11 produced, the Producing Party must determine which documents, or portions 12 thereof, qualify for protection under this Order. Then, before producing the 13 specified documents, the Producing Party must affix the “CONFIDENTIAL legend” 14 to each page that contains Protected Material. If only a portion of the material on a 15 page qualifies for protection, the Producing Party also must clearly identify the 16 protected portion(s) (e.g., by making appropriate markings in the margins). 17 (b) for testimony given in depositions that the Designating Party 18 identifies the Disclosure or Discovery Material on the record, before the close of the 19 deposition all protected testimony. 20 (c) for information produced in some form other than documentary and 21 for any other tangible items, that the Producing Party affix in a prominent place on 22 the exterior of the container or containers in which the information is stored the 23 legend “CONFIDENTIAL.” If only a portion or portions of the information 24 warrants protection, the Producing Party, to the extent practicable, shall identify the 25 protected portion(s). 26 5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 27 failure to designate qualified information or items does not, standing alone, waive 1 the Designating Party’s right to secure protection under this Order for such material. 2 Upon timely correction of a designation, the Receiving Party must make reasonable 3 efforts to assure that the material is treated in accordance with the provisions of this 4 Order. 5 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 6 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 7 designation of confidentiality at any time that is consistent with the Court’s 8 Scheduling Order. 9 6.2 Meet and Confer. The Challenging Party shall initiate the dispute 10 resolution process under Local Rule 37-1 et seq. 11 6.3 Joint Stipulation. Any challenge submitted to the Court shall be via a 12 joint stipulation pursuant to Local Rule 37-2. 13 6.3 The burden of persuasion in any such challenge proceeding shall be on 14 the Designating Party. Frivolous challenges, and those made for an improper 15 purpose (e.g., to harass or impose unnecessary expenses and burdens on other 16 parties) may expose the Challenging Party to sanctions. Unless the Designating 17 Party has waived or withdrawn the confidentiality designation, all parties shall 18 continue to afford the material in question the level of protection to which it is 19 entitled under the Producing Party’s designation until the Court rules on the 20 challenge. 21 7. ACCESS TO AND USE OF PROTECTED MATERIAL 22 7.1 Basic Principles. A Receiving Party may use Protected Material that is 23 disclosed or produced by another Party or by a Non-Party in connection with this 24 Action only for prosecuting, defending or attempting to settle this Action. Such 25 Protected Material may be disclosed only to the categories of persons and under the 26 conditions described in this Order. When the Action has been terminated, a 27 Receiving Party must comply with the provisions of section 13 below (FINAL 1 DISPOSITION). Protected Material must be stored and maintained by a Receiving 2 Party at a location and in a secure manner that ensures that access is limited to the 3 persons authorized under this Order. 4 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 5 otherwise ordered by the court or permitted in writing by the Designating Party, a 6 Receiving Party may disclose any information or item designated 7 “CONFIDENTIAL” only to: 8 (a) the Receiving Party’s Outside Counsel of Record in this Action, as well 9 as employees of said Outside Counsel of Record to whom it is reasonably necessary 10 to disclose the information for this Action; 11 (b) the officers, directors, and employees (including House Counsel) of the 12 Receiving Party to whom disclosure is reasonably necessary for this Action; 13 (c) Experts (as defined in this Order) of the Receiving Party to whom 14 disclosure is reasonably necessary for this Action and who have signed the 15 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 16 (d) the court and its personnel; 17 (e) court reporters and their staff; 18 (f) professional jury or trial consultants, mock jurors, and Professional 19 Vendors to whom disclosure is reasonably necessary for this Action and who have 20 signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A); 21 (g) the author or recipient of a document containing the information or a 22 custodian or other person who otherwise possessed or knew the information; 23 (h) during their depositions, witnesses, and attorneys for witnesses, in the 24 Action to whom disclosure is reasonably necessary provided: (1) the deposing party 25 requests that the witness sign the form attached as Exhibit 1 hereto; and (2) they will 26 not be permitted to keep any confidential information unless they sign the 27 “Acknowledgment and Agreement to Be Bound” (Exhibit A), unless otherwise 1 agreed by the Designating Party or ordered by the court. Pages of transcribed 2 deposition testimony or exhibits to depositions that reveal Protected Material may 3 be separately bound by the court reporter and may not be disclosed to anyone except 4 as permitted under this Stipulated Protective Order; and 5 (i) any mediator or settlement officer, and their supporting personnel, 6 mutually agreed upon by any of the parties engaged in settlement discussions. 7 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED IN 8 OTHER LITIGATION 9 If a Party is served with a subpoena or a court order issued in other litigation 10 that compels disclosure of any information or items designated in this Action as 11 “CONFIDENTIAL,” that Party must: 12 (a) promptly notify in writing the Designating Party. Such notification shall 13 include a copy of the subpoena or court order; 14 (b) promptly notify in writing the party who caused the subpoena or order to 15 issue in the other litigation that some or all of the material covered by the subpoena 16 or order is subject to this Protective Order. Such notification shall include a copy of 17 this Stipulated Protective Order; and 18 (c) cooperate with respect to all reasonable procedures sought to be pursued 19 by the Designating Party whose Protected Material may be affected. If the 20 Designating Party timely seeks a protective order, the Party served with the 21 subpoena or court order shall not produce any information designated in this action 22 as “CONFIDENTIAL” before a determination by the court from which the 23 subpoena or order issued, unless the Party has obtained the Designating Party’s 24 permission. The Designating Party shall bear the burden and expense of seeking 25 protection in that court of its confidential material and nothing in these provisions 26 should be construed as authorizing or encouraging a Receiving Party in this Action 27 to disobey a lawful directive from another court. 1 9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE 2 PRODUCED IN THIS LITIGATION 3 (a) The terms of this Order are applicable to information produced by a 4 Non-Party in this Action and designated as “CONFIDENTIAL.” Such information 5 produced by Non-Parties in connection with this litigation is protected by the 6 remedies and relief provided by this Order. Nothing in these provisions should be 7 construed as prohibiting a Non-Party from seeking additional protections. 8 (b) In the event that a Party is required, by a valid discovery request, to 9 produce a Non-Party’s confidential information in its possession, and the Party is 10 subject to an agreement with the Non-Party not to produce the Non-Party’s 11 confidential information, then the Party shall: 12 (1) promptly notify in writing the Requesting Party and the Non- 13 Party that some or all of the information requested is subject to a confidentiality 14 agreement with a Non-Party; 15 (2) promptly provide the Non-Party with a copy of the 16 Stipulated Protective Order in this Action, the relevant discovery request(s), and a 17 reasonably specific description of the information requested; and 18 (3) make the information requested available for inspection by 19 the Non-Party, if requested. 20 (c) If the Non-Party fails to seek a protective order from this court 21 within 14 days of receiving the notice and accompanying information, the Receiving 22 Party may produce the Non-Party’s confidential information responsive to the 23 discovery request. If the Non-Party timely seeks a protective order, the Receiving 24 Party shall not produce any information in its possession or control that is subject to 25 the confidentiality agreement with the Non-Party before a determination by the 26 court. Absent a court order to the contrary, the Non-Party shall bear the burden and 27 expense of seeking protection in this court of its Protected Material. 1 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 2 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 3 Protected Material to any person or in any circumstance not authorized under this 4 Stipulated Protective Order, the Receiving Party must immediately (a) notify in 5 writing the Designating Party of the unauthorized disclosures, (b) use its best efforts 6 to retrieve all unauthorized copies of the Protected Material, (c) inform the person or 7 persons to whom unauthorized disclosures were made of all the terms of this Order, 8 and (d) request such person or persons to execute the “Acknowledgment and 9 Agreement to Be Bound” that is attached hereto as Exhibit A. 10 11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 11 PROTECTED MATERIAL 12 When a Producing Party gives notice to Receiving Parties that certain 13 inadvertently produced material is subject to a claim of privilege or other protection, 14 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 15 Procedure 26(b)(5)(B). This provision is not intended to modify whatever procedure 16 may be established in an e-discovery order that provides for production without prior 17 privilege review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the 18 parties reach an agreement on the effect of disclosure of a communication or 19 information covered by the attorney-client privilege or work product protection, the 20 parties may incorporate their agreement in the stipulated protective order submitted 21 to the court. 22 12. MISCELLANEOUS 23 12.1 Right to Further Relief. Nothing in this Order abridges the right of any 24 person to seek its modification by the Court in the future. 25 12.2 Right to Assert Other Objections. By stipulating to the entry of this 26 Protective Order, no Party waives any right it otherwise would have to object to 27 disclosing or producing any information or item on any ground not addressed in this 1 Stipulated Protective Order. Similarly, no Party waives any right to object on any 2 ground to use in evidence of any of the material covered by this Protective Order. 3 12.3 Filing Protected Material. A Party that seeks to file under seal any 4 Protected Material must comply with Local Civil Rule 79-5. Protected Material 5 may only be filed under seal pursuant to a court order authorizing the sealing of the 6 specific Protected Material at issue. If a Party’s request to file Protected Material 7 under seal is denied by the court, then the Receiving Party may file the information 8 in the public record unless otherwise instructed by the court. 9 13. FINAL DISPOSITION 10 After the final disposition of this Action, as defined in paragraph 4, within 60 11 days of a written request by the Designating Party, each Receiving Party must return 12 all Protected Material to the Producing Party or destroy such material. As used in 13 this subdivision, “all Protected Material” includes all copies, abstracts, compilations, 14 summaries, and any other format reproducing or capturing any of the Protected 15 Material. Whether the Protected Material is returned or destroyed, the Receiving 16 Party must submit a written certification to the Producing Party (and, if not the same 17 person or entity, to the Designating Party) by the 60 day deadline that (1) identifies 18 (by category, where appropriate) all the Protected Material that was returned or 19 destroyed and (2) affirms that the Receiving Party has not retained any copies, 20 abstracts, compilations, summaries or any other format reproducing or capturing any 21 of the Protected Material. Notwithstanding this provision, Counsel are entitled to 22 retain an archival copy of all pleadings, motion papers, trial, deposition, and hearing 23 transcripts, legal memoranda, correspondence, deposition and trial exhibits, expert 24 reports, attorney work product, and consultant and expert work product, even if such 25 materials contain Protected Material. Any such archival copies that contain or 26 constitute Protected Material remain subject to this Protective Order as set forth in 27 Section 4 (DURATION). 1 14. VIOLATION 2 Any violation of this Order may be punished by appropriate measures including, 3 without limitation, contempt proceedings and/or monetary sanctions. 4 5 FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. 6 7 DATED: June 23, 2021 __/s_/_ C__h_ar_l_e_s _F_. _E_i_c_k_________________ HON. CHARLES F. EICK 8 United States Magistrate Judge 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 1 EXHIBIT A 2 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND 3 4 I, ___________________________________________ [print or type full name], of 5 _____________________________________________________ [full address], 6 declare under penalty of perjury that I have read in its entirety and understand the 7 Stipulated Protective Order that was issued by the United States District Court for 8 the Central District of California on __________ [date] in the case of Hyacinth 9 Livingston v. Lowe’s Home Centers, LLC, Case No. 2:21-cv-04027-AB (Ex). I 10 agree to comply with and to be bound by all the terms of this Stipulated Protective 11 Order and I understand and acknowledge that failure to so comply could expose me 12 to sanctions and punishment in the nature of contempt. I solemnly promise that I 13 will not disclose in any manner any information or item that is subject to this 14 Stipulated Protective Order to any person or entity except in strict compliance with 15 the provisions of this Order. I further agree to submit to the jurisdiction of the 16 United States District Court for the Central District of California for enforcing the 17 terms of this Stipulated Protective Order, even if such enforcement proceedings 18 occur after termination of this action. I hereby appoint _______________________ 19 [full name] of _______________________________________ [full address and 20 telephone number] as my California agent for service of process in connection with 21 this action or any proceedings related to enforcement of this Stipulated Protective 22 Order. 23 Date: ______________________________________ 24 City and State where sworn and signed: _________________________________ 25 Printed name: _______________________________ 26 27 Signature: __________________________________