1 BILAL A. ESSAYLI United States Attorney 2 DAVID M. HARRIS Assistant United States Attorney 3 Chief, Civil Division JOANNE S. OSINOFF 4 Assistant United States Attorney Chief, Complex and Defensive Litigation Section 5 JOSEPH W. TURSI (Cal. Bar No. 300063) Assistant United States Attorney 6 Federal Building, Suite 7516 300 North Los Angeles Street 7 Los Angeles, California 90012 Telephone: (213) 894-3989 8 Facsimile: (213) 894-7819 E-mail: [email protected] 9 Attorneys for Defendants 10 11 UNITED STATES DISTRICT COURT 12 CENTRAL DISTRICT OF CALIFORNIA 13 14 Case No. 2:24-cv-08915-CBM-SK 15 GIORGI METREVELI, DISCOVERY MATTER 16 Plaintiff, 17 v. STIPULATED PROTECTIVE 18 ORDER1 KIKA SCOTT, Senior Official 19 Performing the Duties of Director of the United States Citizenship and 20 Immigration Services, et al. Honorable Steve Kim 21 Defendants. United States Magistrate Judge 22 23 24 25 26 27 1 This Stipulated Protective Order is substantially based on the model protective order provided under Magistrate Judge Steve Kim’s Requirements and 28 1 1. A. PURPOSES AND LIMITATIONS 2 Discovery in this action is likely to involve production of confidential, 3 proprietary, or private information for which special protection from public 4 disclosure and from use for any purpose other than prosecuting this litigation may 5 be warranted, including case-specific, asylum-related, or private information 6 relating to Plaintiff. Accordingly, the parties hereby stipulate to and petition the 7 Court to enter the following Stipulated Protective Order. The parties acknowledge 8 that this Order does not confer blanket protections on all disclosures or responses to 9 discovery and that the protection it affords from public disclosure and use extends 10 only to the limited information or items that are entitled to confidential treatment 11 under the applicable legal principles. The parties further acknowledge, as set forth 12 in Section 12.3 (Filing Protected Material), below, that this Stipulated Protective 13 Order does not entitle them to file confidential information under seal; Civil Local 14 Rule 79-5 sets forth the procedures that must be followed and the standards that will 15 be applied when a party seeks permission from the court to file material under seal. 16 B. GOOD CAUSE STATEMENT 17 As contemplated by the parties in their Joint Rule 26(f) Report, Dkt. 16, the 18 parties anticipate the filing of a Certified Administrative Record of the Plaintiff’s 19 asylum application filed with Defendant United States Citizenship and Immigration 20 Services on or about June 2, 2020 (the “CAR”). The CAR is likely 21 to contain personally identifiable information and information regarding the 22 Plaintiff’s asylum application including information regarding Plaintiff’s prior 23 persecution and fear of future persecution that is protected by law. See

208.6 (governing the disclosure of information contained in or pertaining to any 25 asylum application). Disclosure of asylum-related information may subject an 26 asylum applicant to retaliatory measures by government authorities or non-state 27 actors in the event that an asylum applicant is repatriated, or endanger the security 28 of the applicant’s family members still residing in the applicant’s country of origin. 1 See USCIS Fact Sheet: Federal Regulation Protecting the Confidentiality of Asylum 2 Applicants, available at https://www.uscis.gov/sites/default/files/document/fact- 3 sheets/Asylum-ConfidentialityFactSheet.pdf (last visited May 22, 2025). 4 Accordingly, to expedite the flow of information, to facilitate the prompt 5 resolution of disputes over confidentiality of discovery materials, to adequately 6 protect information the parties are entitled to keep confidential, to ensure that the 7 parties are permitted reasonable necessary uses of such material in preparation for 8 and in the conduct of trial, to address their handling at the end of the litigation, and 9 serve the ends of justice, a protective order for such information is justified in this 10 matter. It is the intent of the parties that information will not be designated as 11 confidential for tactical reasons and that nothing be so designated without a good 12 faith belief that it has been maintained in a confidential, non-public manner, and 13 there is good cause why it should not be part of the public record of this case. 14 2. DEFINITIONS 15 2.1 Action: Giorgi Metreveli v. Kika Scott, et al. C.D. CA Case No. 2:24- 16 cv-08915-CBM-SK. 17 2.2 Challenging Party: a Party or Non-Party that challenges the 18 designation of information or items under this Order. 19 2.3 “CONFIDENTIAL” Information or Items: information (regardless of 20 how it is generated, stored, or maintained) or tangible things that qualify for 21 protection under Federal Rule of Civil Procedure 26(c), and as specified above in 22 the Good Cause Statement, including the CAR, and 23 (i) Information, documents or tangible things protected by the Privacy 24 Act, 5 U.S.C. § 552a, et seq., or information that would be covered by 25 the Privacy Act if the subject of the information had been a U.S. citizen 26 or a person lawfully admitted for permanent residence; 27 (ii) Information, documents or tangible things—which may include, 28 among other things, Department of Homeland Security, Immigration 1 and Customs Enforcement and U.S. Citizenship and Immigration 2 Services records regarding law enforcement activities and operations, 3 internal policies, processes and procedures, and internal 4 investigations—which contain information that is law enforcement 5 sensitive, for instance, information which would be protected from 6 disclosure under FOIA,

, et seq., under the exemption 7 found at

(b)(7)(E). 8 (iii) Information contained in or pertaining to: (1) asylum claims or 9 applications including applications for relief under the Convention 10 Against Torture (“CAT”) and refugee information; and 11 (iv) Any identifying information that is not publicly available and qualifies 12 for protection under applicable law, statutes or regulations (including 13 8 C.F.R. 208.6), including, but not limited to: (i) the names, addresses, 14 date of birth, and “A” number of the particular individual(s) to whom 15 information relates and any other personally identifiable information 16 identified in Federal Rule of Civil Procedure 5.2; and (ii) any 17 personally identifiable information related to third parties other than 18 the individual whose information is being sought. 19 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as 20 their support staff). 21 2.5 Designating Party: a Party or Non-Party that designates information 22 or items that it produces in disclosures or in responses to discovery as 23 “CONFIDENTIAL.” 24 2.6 Disclosure or Discovery Material: all items or information, regardless 25 of the medium or manner in which it is generated, stored, or maintained (including, 26 among other things, testimony, transcripts, and tangible things), that are produced 27 or generated in disclosures or responses to discovery in this matter, including the 28 CAR. 1 2.7 Expert: a person with specialized knowledge or experience in a matter 2 pertinent to the litigation who has been retained by a Party or its counsel to serve as 3 an expert witness or as a consultant in this Action. 4 2.8 House Counsel: attorneys who are employees of a party to this Action. 5 House Counsel does not include Outside Counsel of Record or any other outside 6 counsel. 7 2.9 Non-Party: any natural person, partnership, corporation, association, 8 or other legal entity not named as a Party to this action. 9 2.10 Outside Counsel of Record: attorneys who are not employees of a 10 party to this Action but are retained to represent or advise a party to this Action and 11 have appeared in this Action on behalf of that party or are affiliated with a law firm 12 which has appeared on behalf of that party, including support staff. 13 2.11 Party: any party to this Action, including all of its officers, directors, 14 employees, consultants, retained experts, and Outside Counsel of Record (and their 15 support staffs). 16 2.12 Producing Party: a Party or Non-Party that produces Disclosure or 17 Discovery Material in this Action. 18 2.13 Professional Vendors: persons or entities that provide litigation 19 support services (e.g., photocopying, videotaping, translating, preparing exhibits or 20 demonstrations, and organizing, storing, or retrieving data in any form or medium) 21 and their employees and subcontractors. 22 2.14 Protected Material: any Disclosure or Discovery Material that is 23 designated as “CONFIDENTIAL.” 24 2.15 Receiving Party: a Party that receives Disclosure or Discovery 25 Material from a Producing Party. 26 3. SCOPE 27 The protections conferred by this Stipulation and Order cover not only 28 Protected Material (as defined above), but also (1) any information copied or 1 extracted from Protected Material; (2) all copies, excerpts, summaries, or 2 compilations of Protected Material; and (3) any testimony, conversations, or 3 presentations by Parties or their Counsel that might reveal Protected Material. 4 Any use of Protected Material at trial shall be governed by the orders of the 5 trial judge. This Order does not govern the use of Protected Material at trial. 6 4. DURATION 7 Once a case proceeds to trial, all of the information that was designated as 8 confidential or maintained pursuant to this protective order becomes public and will 9 be presumptively available to all members of the public, including the press, unless 10 compelling reasons supported by specific factual findings to proceed otherwise are 11 made to the trial judge in advance of the trial. See Kamakana v. City and County of 12 Honolulu,

, 1180-81 (9th Cir. 2006) (distinguishing “good cause” 13 showing for sealing documents produced in discovery from “compelling reasons” 14 standard when merits-related documents are part of court record). Accordingly, the 15 terms of this protective order do not extend beyond the commencement of the trial. 16 Notwithstanding the above, the CAR shall remain subject to the provisions of 17 this protective order indefinitely. 18 5. DESIGNATING PROTECTED MATERIAL 19 5.1 Exercise of Restraint and Care in Designating Material for Protection. 20 Each Party or Non-Party that designates information or items for protection under 21 this Order must take care to limit any such designation to specific material that 22 qualifies under the appropriate standards. The Designating Party must designate for 23 protection only those parts of material, documents, items, or oral or written 24 communications that qualify so that other portions of the material, documents, 25 items, or communications for which protection is not warranted are not swept 26 unjustifiably within the ambit of this Order. 27 Mass, indiscriminate, or routinized designations are prohibited. Designations 28 that are shown to be clearly unjustified or that have been made for an improper 1 purpose (e.g., to unnecessarily encumber the case development process or to impose 2 unnecessary expenses and burdens on other parties) may expose the Designating 3 Party to sanctions. 4 If it comes to a Designating Party’s attention that information or items that it 5 designated for protection do not qualify for protection, that Designating Party must 6 promptly notify all other Parties that it is withdrawing the inapplicable designation. 7 5.2 Manner and Timing of Designations. Except as otherwise provided in 8 this Order (see, e.g., second paragraph of Section 5.2(a) below), or as otherwise 9 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection 10 under this Order must be clearly so designated before the material is disclosed or 11 produced, or in the case of the CAR, designated in conformity with this Order at the 12 time of filing. 13 Designation in conformity with this Order requires: 14 (a) for information in documentary form (e.g., paper or electronic 15 documents, but excluding transcripts of depositions or other pretrial or trial 16 proceedings), that the Producing Party affix at a minimum, the legend 17 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 18 contains protected material. If only a portion or portions of the material on a page 19 qualifies for protection, the Producing Party also must clearly identify the protected 20 portion(s) (e.g., by making appropriate markings in the margins). 21 A Party or Non-Party that makes original documents available for 22 inspection need not designate them for protection until after the inspecting Party has 23 indicated which documents it would like copied and produced. During the 24 inspection and before the designation, all of the material made available for 25 inspection shall be deemed “CONFIDENTIAL.” After the inspecting Party has 26 identified the documents it wants copied and produced, the Producing Party must 27 determine which documents, or portions thereof, qualify for protection under this 28 Order. Then, before producing the specified documents, the Producing Party must 1 affix the “CONFIDENTIAL legend” to each page that contains Protected Material. 2 If only a portion or portions of the material on a page qualifies for protection, the 3 Producing Party also must clearly identify the protected portion(s) (e.g., by making 4 appropriate markings in the margins). 5 (b) for testimony given in depositions that the Designating Party identify 6 the Disclosure or Discovery Material on the record, before the close of the 7 deposition all protected testimony. 8 (c) for information produced in some form other than documentary and 9 for any other tangible items, that the Producing Party affix in a prominent place on 10 the exterior of the container or containers in which the information is stored the 11 legend “CONFIDENTIAL.” If only a portion or portions of the information 12 warrants protection, the Producing Party, to the extent practicable, shall identify the 13 protected portion(s). 14 5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 15 failure to designate qualified information or items does not, standing alone, waive 16 the Designating Party’s right to secure protection under this Order for such material. 17 Upon timely correction of a designation, the Receiving Party must make reasonable 18 efforts to assure that the material is treated in accordance with the provisions of this 19 Order. 20 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 21 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 22 designation of confidentiality at any time that is consistent with the Court’s 23 Scheduling Order. 24 6.2 Meet and Confer. The Challenging Party Shall initiate the dispute 25 resolution process under Civil Local Rule 37-1 et seq. 26 6.3 The burden of persuasion in any such challenge proceeding shall be 27 on the Designating Party. Frivolous challenges, and those made for an improper 28 purpose (e.g., to harass or impose unnecessary expenses and burdens on other 1 parties), may expose the Challenging Party to sanctions. Unless the Designating 2 Party has waived or withdrawn the confidentiality designation, all parties shall 3 continue to afford the material in question the level of protection to which it 4 is entitled under the Producing Party’s designation until the Court rules on the 5 challenge. 6 7. ACCESS TO AND USE OF PROTECTED MATERIAL 7 7.1 Basic Principles. A Receiving Party may use Protected Material that 8 is disclosed or produced by another Party or by a Non-Party in connection with 9 this Action only for prosecuting, defending, or attempting to settle this Action. 10 Such Protected Material may be disclosed only to the categories of persons and 11 under the conditions described in this Order. When the Action has been 12 terminated, a Receiving Party must comply with the provisions of Section 13 below 13 (FINAL DISPOSITION). 14 Protected Material must be stored and maintained by a Receiving Party at 15 a location and in a secure manner that ensures that access is limited to the 16 persons authorized under this Order. 17 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 18 otherwise ordered by the Court or permitted in writing by the Designating Party, a 19 Receiving Party may disclose any information or item designated 20 “CONFIDENTIAL” only to: 21 (a) the Receiving Party’s Outside Counsel of Record in this Action, as 22 well as employees of said Outside Counsel of Record to whom it is reasonably 23 necessary to disclose the information for this Action; 24 (b) the officers, directors, and employees (including House Counsel) of 25 the Receiving Party to whom disclosure is reasonably necessary for this Action; 26 (c) Experts (as defined in this Order) of the Receiving Party to whom 27 disclosure is reasonably necessary for this Action and who have signed the 28 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 1 (d) the Court and its personnel; 2 (e) court reporters and their staff; 3 (f) professional jury or trial consultants, mock jurors, and Professional 4 Vendors to whom disclosure is reasonably necessary for this Action and who have 5 signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A); 6 (g) the author or recipient of a document containing the information or a 7 custodian or other person who otherwise possessed or knew the information; 8 (h) during their depositions, witnesses, and attorneys for witnesses, in 9 the Action to whom disclosure is reasonably necessary provided: (1) the deposing 10 party requests that the witness sign the form attached as Exhibit A hereto; and (2) 11 they will not be permitted to keep any confidential information unless they sign the 12 “Acknowledgment and Agreement to Be Bound” (Exhibit A), unless otherwise 13 agreed by the Designating Party or ordered by the Court. Pages of transcribed 14 deposition testimony or exhibits to depositions that reveal Protected Material may 15 be separately bound by the court reporter and may not be disclosed to anyone except 16 as permitted under this Stipulated Protective Order; and 17 (i) any mediator or settlement officer, and their supporting personnel, 18 mutually agreed upon by any of the parties engaged in settlement discussions. 19 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED 20 IN OTHER LITIGATION 21 If a Party is served with a subpoena or a court order issued in other litigation 22 that compels disclosure of any information or items designated in this Action as 23 “CONFIDENTIAL,” that Party must: 24 (a) promptly notify in writing the Designating Party. Such notification 25 shall include a copy of the subpoena or court order; 26 (b) promptly notify in writing the party who caused the subpoena or order 27 to issue in the other litigation that some or all of the material covered by the 28 subpoena or order is subject to this Protective Order. Such notification shall include 1 a copy of this Stipulated Protective Order; and 2 (c) cooperate with respect to all reasonable procedures sought to be 3 pursued by the Designating Party whose Protected Material may be affected. 4 If the Designating Party timely seeks a protective order, the Party served with 5 the subpoena or court order shall not produce any information designated in this 6 action as “CONFIDENTIAL” before a determination by the court from which the 7 subpoena or order issued, unless the Party has obtained the Designating Party’s 8 permission. The Designating Party shall bear the burden and expense of seeking 9 protection in that court of its confidential material, and nothing in these provisions 10 should be construed as authorizing or encouraging a Receiving Party in this Action 11 to disobey a lawful directive from another court. 12 9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE 13 PRODUCED IN THIS LITIGATION 14 (a) The terms of this Order are applicable to information produced by a 15 Non-Party in this Action and designated as “CONFIDENTIAL.” Such information 16 produced by Non-Parties in connection with this litigation is protected by the 17 remedies and relief provided by this Order. Nothing in these provisions should be 18 construed as prohibiting a Non-Party from seeking additional protections. 19 (b) In the event that a Party is required, by a valid discovery request, to 20 produce a Non-Party’s confidential information in its possession, and the Party is 21 subject to an agreement with the Non-Party not to produce the Non-Party’s 22 confidential information, then the Party shall: 23 (1) promptly notify in writing the Requesting Party and the Non-Party 24 that some or all of the information requested is subject to a confidentiality agreement 25 with a Non-Party; 26 (2) promptly provide the Non-Party with a copy of the Stipulated 27 Protective Order in this Action, the relevant discovery request(s), and a reasonably 28 specific description of the information requested; and 1 (3) make the information requested available for inspection by the Non- 2 Party, if requested. 3 (c) If the Non-Party fails to seek a protective order from this Court within 4 14 days of receiving the notice and accompanying information, the Receiving Party 5 may produce the Non-Party’s confidential information responsive to the discovery 6 request. If the Non-Party timely seeks a protective order, the Receiving Party shall 7 not produce any information in its possession or control that is subject to the 8 confidentiality agreement with the Non-Party before a determination by the Court. 9 Absent a court order to the contrary, the Non-Party shall bear the burden and 10 expense of seeking protection in this Court of its Protected Material. 11 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 12 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 13 Protected Material to any person or in any circumstance not authorized under this 14 Stipulated Protective Order, the Receiving Party must immediately (a) notify in 15 writing the Designating Party of the unauthorized disclosures, (b) use its best efforts 16 to retrieve all unauthorized copies of the Protected Material, (c) inform the person 17 or persons to whom unauthorized disclosures were made of all the terms of this 18 Order, and (d) request such person or persons to execute the “Acknowledgment and 19 Agreement to Be Bound” that is attached hereto as Exhibit A. 20 11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 21 PROTECTED MATERIAL 22 When a Producing Party gives notice to Receiving Parties that certain 23 inadvertently produced material is subject to a claim of privilege or other protection, 24 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 25 Procedure 26(b)(5)(B). This provision is not intended to modify whatever 26 procedure may be established in an e-discovery order that provides for production 27 without prior privilege review. Pursuant to Federal Rule of Evidence 502(d) and 28 (e), insofar as the parties reach an agreement on the effect of disclosure of a 1 communication or information covered by the attorney-client privilege or work 2 product protection, the parties may incorporate their agreement in the stipulated 3 protective order submitted to the Court. 4 12. MISCELLANEOUS 5 12.1 Right to Relief. Nothing in this Order abridges the right of any person 6 to seek its modification by the Court in the future. 7 12.2 Right to Assert Other Objections. By stipulating to the entry of this 8 Protective Order, no Party waives any right it otherwise would have to object to 9 disclosing or producing any information or item on any ground not addressed in this 10 Stipulated Protective Order. Similarly, no Party waives any right to object on any 11 ground to use in evidence of any of the material covered by this Protective Order. 12 12.3 Filing Protected Material. A Party that seeks to file under seal any 13 Protected Material must comply with Civil Local Rule 79-5. Protected Material 14 may only be filed under seal pursuant to a court order authorizing the sealing of the 15 specific Protected Material at issue. If a Party’s request to file Protected Material 16 under seal is denied by the court, then the Receiving Party may file the information 17 in the public record unless otherwise instructed by the court. 18 13. FINAL DISPOSITION 19 Final disposition shall be deemed to be the later of (1) dismissal of all claims 20 and defenses in this Action, with or without prejudice; and (2) final judgment herein 21 after the completion and exhaustion of all appeals, rehearings, remands, trials, or 22 reviews of this Action, including the time limits for filing any motions or 23 applications for extension of time pursuant to applicable law. After the final 24 disposition of this Action, within 60 days of a written request by the Designating 25 Party, each Receiving Party must return all Protected Material to the Producing 26 Party or destroy such material. As used in this subdivision, “all Protected Material” 27 includes all copies, abstracts, compilations, summaries, and any other format 28 reproducing or capturing any of the Protected Material. Whether the Protected 1 Material is returned or destroyed, the Receiving Party must submit a written 2 certification to the Producing Party (and, if not the same person or entity, to the 3 Designating Party) by the 60 day deadline that (1) identifies (by category, where 4 appropriate) all the Protected Material that was returned or destroyed; and (2) 5 affirms that the Receiving Party has not retained any copies, abstracts, compilations, 6 summaries, or any other format reproducing or capturing any of the Protected 7 Material. Notwithstanding this provision, Counsel are entitled to retain an archival 8 copy of all pleadings, motion papers, trial, deposition, and hearing transcripts, legal 9 memoranda, correspondence, deposition and trial exhibits, expert reports, attorney 10 work product, and consultant and expert work product, even if such materials 11 contain Protected Material. Any such archival copies that contain or constitute 12 Protected Material remain subject to this Protective Order as set forth in Section 4 13 (DURATION). 14 14. Any violation of this Order may be punished by any and all appropriate 15 measures including, without limitation, contempt proceedings and/or 16 monetary sanctions. 17 18 IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD. 19 20 DATED ____June 5, 2025_______________ 21 MINEVICH LAW, APC 22

23 /s/ Gary Minevick Gary Minevich 24 Attorney for Plaintiff 25

26

27

28 1] DATED: June 5, 2025 2 BILAL A. ESSAYLI 3 |United States Attorney DAVID M. HARRIS 4 | Assistant United States Attorney Chief, Civil Division 5 |JOANNE S. OSINOFF Assistant United States Attomey - 6 | Chief, Complex and Defensive Litigation Section 7 /s/ Joseph W_Tursi 8 |JOSEPH W. TURSI 9 Assistant United States Attorney 10] Attorneys for Defendants 11] FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. 12 DATED: June 6, 2025 14

16| Honorable Steve Kim 17] United States Magistrate Judge 18 19 20 21 22 23 24 25 26 27 28

1 EXHIBIT A 2 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND 3 4 I, _____________________________ [print or type full name], of 5 _________________ [print or type full address], declare under penalty of perjury 6 that I have read in its entirety and understand the Stipulated Protective Order that 7 was issued by the United States District Court for the Central District of California 8 in the case of Giorgi Metreveli v. Kika Scott, et al. C.D. CA Case No. 2:24-cv- 9 08915-CBM-SK. I agree to comply with and to be bound by all the terms of this 10 Stipulated Protective Order, and I understand and acknowledge that failure to so 11 comply could expose me to sanctions and punishment in the nature of contempt. I 12 solemnly promise that I will not disclose in any manner any information or item that 13 is subject to this Stipulated Protective Order to any person or entity except in strict 14 compliance with the provisions of this Order. 15 I further agree to submit to the jurisdiction of the United States District Court 16 for the Central District of California for the purpose of enforcing the terms of this 17 Stipulated Protective Order, even if such enforcement proceedings occur after 18 termination of this action. I hereby appoint __________________________ [print 19 or type full name] of _______________________________________ [print or type 20 full address and telephone number] as my California agent for service of process in 21 connection with this action or any proceedings related to enforcement of this 22 Stipulated Protective Order. 23 Date: ______________________________________ 24 City and State where sworn and signed: _________________________________ 25 26 Printed name: _______________________________ 27 28 Signature: __________________________________