1 Thomas C. Hurrell, State Bar No. 119876 E-Mail: [email protected] 2 Maria Tuason, State Bar No. 256397 E-Mail: [email protected] 3 Dorisa Shahmirzai, State Bar No. 254024 E-Mail: [email protected] 4 HURRELL CANTRALL LLP 300 South Grand Avenue, Suite 1300 5 Los Angeles, California 90071 Telephone: (213) 426-2000 6 Facsimile: (213) 426-2020 7 Attorneys for Defendants, COUNTY OF LOS ANGELES, and DEPUTY ERIC MORENO 8 9 Peter L. Carr, IV, State Bar No. 256104 E-Mail: [email protected] 10 Na’Shaun L. Neal, State Bar No. 284280 E-Mail: [email protected] 11 Lauren K. McRae, State Bar No. 331296 E-Mail: [email protected] 12 PLC LAW GROUP, APC 3756 Santa Rosalia Dr., Suite 326 13 Los Angeles, California 90008 Telephone: (310) 400-5890 14 Facsimile: (310) 400-5895 15 Attorneys for Plaintiff JOSE GUTIERREZ 16 17 UNITED STATES DISTRICT COURT 18 CENTRAL DISTRICT OF CALIFORNIA, WESTERN DIVISION 19 20 JOSE GUTIERREZ, CASE NO. 2:21-cv-08223-FMO(PLA) 21 Plaintiff, DISCOVERY MATTER 22 v. STIPULATED [PROPOSED] PROTECTIVE ORDER 23 COUNTY OF LOS ANGELES; GOVERNING PRODUCTION OF DEPUTY EUGENE CONTRERAS “CONFIDENTIAL” 24 (#516515); DEPUTY ERIC MORENO INFORMATION (#472731) and DOES 1 through 10, 25 inclusive, [Discovery Document: Referred to Magistrate Paul L. Abrams] 26 Defendants. [Assigned to Hon. Fernando M. Olguin, 27 Courtroom "6D"] 1 I. PURPOSE AND LIMITATIONS 2 Discovery in this action is likely to involve production of confidential or 3 private information for which special protection from public disclosure and from use 4 for any purpose other than prosecuting this action may be warranted. Accordingly, 5 the parties hereby stipulate to and petition the Court to enter the following 6 [Proposed] Stipulated Protective Order (hereafter “this Order”). The parties 7 acknowledge that this Order does not confer blanket protections on all disclosures or 8 responses to discovery; and that the protection it affords from public disclosure and 9 use extends only to the limited information or items that are entitled to confidential 10 treatment under the applicable legal principles. 11 II. GOOD CAUSE STATEMENT 12 This action is likely to involve confidential information pertaining to 13 personnel records and other materials subject to privacy protections for which 14 special protection from public disclosure and from use for any purpose other than 15 prosecution of this action is warranted. Limiting disclosure of these documents to 16 the context of this litigation as provided herein will, accordingly, further important 17 law enforcement objectives and interests, including the safety of personnel and the 18 public, as well as the privacy rights of plaintiff, the individual defendants, and third 19 party witnesses. Such confidential materials and information consists of, among 20 other things, materials entitled to privileges and/or protections under the following: 21 the United States Constitution, First Amendment; the California Constitution, 22 Article I, Section 1; California Penal Code §§ 832.5, 832.7, and 832.8; California 23 Evidence Code §§ 1040 and 1043, et seq.; the Privacy Act of 1974, 5 U.S.C. § 552a; 24 Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 25 104-191, decisional law relating to such provisions; and information otherwise 26 generally unavailable to the public; or which may be privileged or otherwise 27 protected from disclosure under state or federal statutes, court rules, case decisions, 1 information consists of materials entitled 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 16 conduct of trial; to address their handling at the end of the litigation; and serve the 17 ends of justice, a protective order for such information is justified in this matter. It 18 is the intent of the parties that information will not be designated as confidential for 19 tactical reasons and that nothing be so designated without a good faith belief that it 20 has been maintained in a confidential, non-public manner; and there is good cause 21 why it 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,

(9th Cir. 2006), Phillips v. Gen. Motors 4 Corp.,

, 1210-11 (9th Cir. 2002), Makar-Welbon v. Sony Electrics, 5 Inc.,

(E.D. Wis. 1999) (even stipulated protective orders 6 require good cause showing, and a specific showing of good cause or compelling 7 reasons with proper evidentiary support and legal justification, must be made with 8 respect to material that a party seeks to file under seal). The parties’ mere 9 designation of material as “CONFIDENTIAL” does not— without the submission 10 of competent evidence by declaration, establishing that the material sought to be 11 filed under seal qualifies as confidential, privileged, or otherwise protectable— 12 constitute good cause. Further, if a party requests sealing related to dispositive 13 motion or trial, then compelling reasons, not only good cause, for the sealing must 14 be shown, and the relief sought shall be narrowly tailored to serve the specific 15 interest to be protected. See Pintos v. Pacific Creditors Ass’n,

, 677-79 16 (9th Cir. 2010). 17 Any document that is not confidential, privileged, or otherwise protectable in 18 its entirety will not be filed under seal if the confidential portions can be redacted. 19 If 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 IV. DEFINITIONS 24 4.1 Action: Jose Gutierrez v. County of Los Angeles, et al. Case No. 2:21- 25 cv-08223. 26 4.2 Challenging Party: a Party or Non-Party that challenges the designation 27 of information or items under this Order. 1 the medium or manner in which it is generated, stored, or maintained) or tangible 2 things that qualify for protection under Federal Rule of Civil Procedure 26(c), and 3 as specified above in the Good Cause Statement. 4 4.4 Counsel: General Counsel of Record and House Counsel (as well as 5 their support staff). 6 4.5 Designating Party: a Party or Non-Party that designated information or 7 items that it produces in disclosures or in responses to discovery as 8 “CONFIDENTIAL.” 9 4.6 Disclosure or Discovery Material: all items or information, regardless 10 of the medium or manner in which it is generated, stored, or maintained (including, 11 among other things, testimony, transcripts, and tangible things), that are produced or 12 generated in disclosures or responses to discovery in this matter. 13 4.7 Expert: a person with specialized knowledge or experience in a matter 14 pertinent to the litigation who has been retained by a Party or its counsel to serve as 15 an expert witness or as a consultant in this Action. 16 4.8 House Counsel: attorneys who are employees of a party to this Action. 17 House Counsel does not include General Counsel of Record or any other outside 18 Counsel. 19 4.9 Non-Party: any natural person, partnership, corporation, association or 20 other legal entity not named as a Party to this action. 21 4.10 General Counsel of Record: attorneys who are not employees of a 22 Party to this Action but are retained to represent or advise a Party to this Action and 23 have appeared in this Action on behalf of that party or are affiliated with a law firm 24 that has appeared on behalf of that Party, as well as their support staff. 25 4.11 Party: any Party to this Action, including all of its officers, directors, 26 employees, consultants, retained experts, and General Counsel of Record (and their 27 support staffs). 1 produces Discovery Material in this Action. 2 4.13 Professional Vendors: persons or entities that provide litigation 3 support services (e.g., photocopying, videotaping, translating, preparing exhibits or 4 demonstrations, and organizing, storing, or retrieving data in any form or medium) 5 and their employees and subcontractors. 6 4.14 Protected Material: any Disclosure or Discovery Material that is 7 designated as “CONFIDENTIAL.” 8 4.15 Producing Party: a Party that makes a Disclosure or produces 9 Discovery Material to the Receiving Party. 10 4.15 Receiving Party: a Party that receives a Disclosure or Discovery 11 Material from a Producing Party. 12 V. 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 15 extracted from Protected Material; (2) all copies, excerpts, summaries, or 16 compilations of Protected Material; and (3) any testimony, conversations, or 17 presentations by Parties or their Counsel (as defined by Sections 4.8 and 4.10) that 18 might reveal Protected Material. 19 Any use of Protected Material at trial shall be governed by the orders of the 20 trial judge. This Order does not govern the use of Protected Material at trial. 21 VI. DURATION 22 The confidentiality obligations imposed by this Order shall remain in effect 23 until Final Disposition of this case. “Final Disposition” shall be deemed to be the 24 later of (1) dismissal of all claims and defenses in this Action, with or without 25 prejudice; and (2) final judgment herein after the completion and exhaustion of all 26 appeals, rehearings, remands, trials, or reviews of this Action, including the time 27 limits for filing any motions or applications for extension of time pursuant to 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 14 Party 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 6 before the designation, all of the materials made available for inspection shall be 7 deemed “CONFIDENTIAL.” After the inspecting Party has identified the 8 documents it wants copied and produced, the Producing Party must determine which 9 documents, or portions thereof, qualify for protection under this Order. Then, 10 before producing the specified documents, the Producing Party must affix the 11 “CONFIDENTIAL legend” to each page that contains Protected Material. If only a 12 portion of the material on a page qualifies for protection, the Producing Party also 13 must clearly identify the protected portion(s) (e.g., by making appropriate markings 14 in the margins). 15 (b) for testimony given in depositions that the Designating Party identifies 16 the Disclosure or Discovery Material on the record, and before the close of the 17 deposition all protected testimony. 18 (c) for information produced in some form other than documentary and for 19 any other tangible items, that the Producing Party affix in a prominent place on the 20 exterior of the container or containers in which the information is stored the legend 21 “CONFIDENTIAL.” If only a portion or portions of the information warrants 22 protection, the Producing Party, to the extent practicable, shall identify the protected 23 portion(s). 24 7.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 25 failure to designate qualified information or items does not, standing alone, waive 26 the Designating Party’s right to secure protection under this Order for such material. 27 Upon timely correction of a designation, the Receiving Party must make reasonable 1 Order. 2 VIII. CHALLENGING CONFIDENTIALITY DESIGNATIONS 3 8.1 Timing of Challenges. Any Party or Non-Party may challenge a 4 designation of confidentiality at any time that is consistent with the Court’s 5 Scheduling Order. 6 8.2 Meet and Confer. The Challenging Party shall initiate the meet and 7 confer process outlined in Local Rule 37.1, et seq. 8 8.3 The burden of persuasion, in any such challenge proceeding, shall be 9 on the Designating Party. Frivolous challenges, and those made for an improper 10 purpose (e.g., to harass or impose unnecessary expenses and burdens on other 11 parties) may expose the Challenging Party to sanctions. Unless the Designating 12 Party has waived or withdrawn the confidentiality designation, all parties shall 13 continue to afford the material in question the level of protection to which it is 14 entitled under the Producing Party’s designation until the Court rules on the 15 challenge. 16 IX. ACCESS TO AND USE OF PROTECTED MATERIAL 17 9.1 Basic Principles. A Receiving Party may use Protected Material that is 18 disclosed or produced by another Party or by a Non-Party in connection with this 19 Action only for prosecuting, defending or attempting to settle this Action. Such 20 Protected Material may be disclosed only to the categories of persons and under the 21 conditions described in this Order. When the Action has been terminated, a 22 Receiving Party must comply with the provisions of Section VI, infra. 23 Protected Material must be stored and maintained by a Receiving Party at a 24 location and in a secure manner that ensures that access is limited to the persons 25 authorized under this Order. 26 9.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 27 otherwise ordered by the Court or permitted in writing by the Designating Party, a 1 “CONFIDENTIAL” only to: 2 (a) the Receiving Party’s General Counsel of Record in this Action, as well 3 as employees of said General Counsel of Record to whom it is reasonably necessary 4 to disclose the information for this Action; 5 (b) the officers, directors, and employees (including House Counsel) of the 6 Receiving Party to whom disclosure is reasonably necessary for this Action; 7 (c) Experts (as defined in this Order) of the Receiving Party to whom 8 disclosure is reasonably necessary for this Action and who have signed the 9 “Acknowledgment and Agreement to Be Bound,” attached and hereafter referred to 10 as “Exhibit A.” 11 (d) the court and its personnel; 12 (e) court reporters and their staff; 13 (f) professional jury or trial consultants, mock jurors, and Professional 14 Vendors to whom disclosure is reasonably necessary for this Action and who have 15 signed Exhibit A. 16 (g) the author or recipient of a document containing the information or a 17 custodian or other person who otherwise possessed or knew the information; 18 (h) during their depositions, witnesses, and attorneys for witnesses, in the 19 Action to whom disclosure is reasonably necessary provided: (1) the deposing party 20 requests that the witness sign Exhibit A; and (2) they will not be permitted to keep 21 any confidential information unless they sign Exhibit A, unless otherwise agreed by 22 the Designating Party or ordered by the Court. Pages of transcribed deposition 23 testimony or exhibits to depositions that reveal Protected Material may be separately 24 bound by the court reporter and may not be disclosed to anyone except as permitted 25 under this Order; and 26 (i) any mediator or settlement officer, and their supporting personnel, 27 mutually agreed upon by any of the parties engaged in settlement discussions. 1 X. PROTECTED MATERIAL SUBPOENAED OR ORDERED 2 PRODUCED IN OTHER LITIGATION 3 If a Party is served with a subpoena or a court order issued in other litigation 4 that compels disclosure of any information or items designated in this Action as 5 “CONFIDENTIAL,” that Party must: 6 (a) promptly notify in writing the Designating Party. Such notification 7 shall include a copy of the subpoena or court order; 8 (b) promptly notify in writing the party who caused the subpoena or order 9 to issue in the other litigation that some or all of the material covered by the 10 subpoena or order is subject to this Order. Such notification shall include a copy of 11 this Order; and 12 (c) cooperate with respect to all reasonable procedures sought to be pursued 13 by the Designating Party whose Protected Material may be affected. 14 If the Designating Party timely seeks a protective order, the Party served with 15 the subpoena or court order shall not produce any information designated in this 16 action as “CONFIDENTIAL” before a determination by the Court from which the 17 subpoena or order issued, unless the Party has obtained the Designating Party’s 18 permission. The Designating Party shall bear the burden and expense of seeking 19 protection in that court of its confidential material and nothing in these provisions 20 should be construed as authorizing or encouraging a Receiving Party in this Action 21 to disobey a lawful directive from another court. 22 XI. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE 23 PRODUCED IN THIS LITIGATION 24 (a) The terms of this Order are applicable to information produced by a 25 Non-Party in this Action and designated as “CONFIDENTIAL.” Such information 26 produced by Non-Parties in connection with this litigation is protected by the 27 remedies and relief provided by this Order. Nothing in these provisions should be 1 (b) In the event that a Party is required, by a valid discovery request, to 2 produce a Non-Party’s confidential information in its possession, and the Party is 3 subject to an agreement with the Non-Party not to produce the Non-Party’s 4 confidential information, then the Party shall: 5 (1) promptly notify in writing the Requesting Party and the Non-Party 6 that some or all of the information requested is subject to a confidentiality 7 agreement with a Non-Party; 8 (2) promptly provide the Non-Party with a copy of this Order in this 9 Action, the relevant discovery request(s), and a reasonably specific description of 10 the information requested; and 11 (3) make the information requested available for inspection by the Non- 12 Party, if requested. 13 (c) If the Non-Party fails to seek a protective order from this Court within 14 fourteen (14) days of receiving the notice and accompanying information, the 15 Receiving Party may produce the Non-Party’s confidential information responsive 16 to the discovery request. If the Non-Party timely seeks a protective order, the 17 Receiving Party shall not produce any information in its possession or control that is 18 subject to the confidentiality agreement with the Non-Party before a determination 19 by the Court. Absent a court order to the contrary, the Non-Party shall bear the 20 burden and expense of seeking protection in this Court of its Protected Material. 21 XII. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 22 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 23 Protected Material to any person or in any circumstance not authorized under this 24 Order, the Receiving Party must immediately (a) notify in writing the Designating 25 Party of the unauthorized disclosures; (b) use its best efforts to retrieve all 26 unauthorized copies of the Protected Material; (c) inform the person or persons to 27 whom unauthorized disclosures were made of all the terms of this Order; and (d) 1 XIII. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 2 PROTECTED MATERIAL 3 When a Producing Party gives notice to Receiving Parties that certain 4 inadvertently produced material is subject to a claim of privilege or other protection, 5 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 6 Procedure 26(b)(5)(B). This provision is not intended to modify whatever 7 procedure may be established in an e-discovery order that provides for production 8 without prior privilege review. Pursuant to Federal Rule of Evidence 502(d) and 9 (e), insofar as the Parties reach an agreement on the effect of disclosure of a 10 communication or information covered by the attorney-client privilege or work 11 product protection, the Parties may incorporate their agreement in a subsequent 12 stipulation to the Court. 13 XIV. MISCELLANEOUS 14 14.1 Right to Further Relief. Nothing in this Order abridges the right of any 15 person to seek its modification by the Court in the future. 16 14.2 Right to Assert Other Objections. By stipulating to the entry of this 17 Order, no Party waives any right it otherwise would have to object to disclosing or 18 producing any information or item on any ground not addressed in this Order. 19 Similarly, no Party waives any right to object on any ground to use in evidence of 20 any of the material covered by this Order. 21 14.3 Filing Protected Material. A Party that seeks to file under seal any 22 Protected Material must comply with Local Civil Rule 79-5. Protected Material 23 may only be filed under seal pursuant to a court order authorizing the sealing of the 24 specific Protected Material at issue. If a Party’s request to file Protected Material 25 under seal is denied by the Court, then the Receiving Party may file the information 26 in the public record unless otherwise instructed by the Court. 27 / / / 1 XV. FINAL DISPOSITION 2 After the final disposition of this Action, as defined in Section VI, supra, 3 within 60 days of a written request by the Designating Party, each Receiving Party 4 must return all Protected Material to the Producing Party or destroy such material. 5 As used in this subdivision, “all Protected Material” includes all copies, abstracts, 6 compilations, summaries, and any other format reproducing or capturing any of the 7 Protected Material. Whether the Protected Material is returned or destroyed, the 8 Receiving Party must submit a written certification to the Producing Party (and, if 9 not the same person or entity, to the Designating Party) by the 60 day deadline that 10 (1) identifies (by category, where appropriate) all the Protected Material that was 11 returned or destroyed and (2) affirms that the Receiving Party has not retained any 12 copies, abstracts, compilations, summaries or any other format reproducing or 13 capturing any of the Protected Material. Notwithstanding this provision, Counsel 14 are entitled to retain an archival copy of all pleadings, motion papers, trial, 15 deposition, and hearing transcripts, legal memoranda, correspondence, deposition 16 and trial exhibits, expert reports, attorney work product, and consultant and expert 17 work product, even if such materials contain Protected Material. Any such archival 18 copies that contain or constitute Protected Material remain subject to this Order as 19 set forth in Section VI, supra. 20 / / / 21 / / / 22 / / / 23 / / / 24 / / / 25 / / / 26 / / / 27 / / / 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: January 3, 2022 PLC LAW GROUP, APC 5 6

8 PETER L. CARR, IV NA’SHAUN L. NEAL g 9 LAUREN K. MCRAE HS. 10 Attorneys for Plaintiff Jose Gutierrez 11 || DATED: January 3, 2022 HURRELL CANTRALL LLP

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14 By: /s/ Dorisa Shahmirzai THOMAS C. HURRELL 15 MARIA TUASON 16 DORISA SHAHMIRZAI Attorneys for Defendants COUNTY OF 17 LOS ANGELES, DEPUTY ERIC 18 MORENO 19 79 || FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. 21 22 DATED: | 1/6/2022 23 Jae x Maovsd- 25 HONORABLE PAUL L. ABRAMS 26 UNITED STATES MAGISTRATE JUDGE 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 Jose Gutierrez v. County of Los Angeles, et al. 8 USDC Case No.: 2:21-cv-08223. I agree to comply with and to be bound by all 9 the terms of this Stipulated Protective Order and I understand and acknowledge that 10 failure to so comply could expose me to sanctions and punishment in the nature of 11 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 13 or entity except in strict compliance with the provisions of this Order. I further 14 agree to submit to the jurisdiction of the United States District Court for the Central 15 District of California for enforcing the terms of this Stipulated Protective Order, 16 even if such 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