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CO URT O F A PPEA L, A PPELLA TE D IS TR IC T, D IV IS IO N T O B E F IL E D I N T H E C O URT O F A PPEALA PP-0 04C IV IL C ASE I N FO RM ATIO N S TA TE M EN TCourt o f A ppe al C ase N um ber if k n ow n):A TTO RNEY O R P AR TY W IT H O UT A TTO RNEY ( N am e, S ta te B ar n um ber, a nd a ddre ss):F O R C O URT U SE O NLYT E LE PH O NE N O .:F A X N O . ( O ptio nal) :E -M AIL A D DR ESS ( O ptio nal) :A TTO RNEY F O R ( N am e):A PPELLA N T:R ESPO NDEN T:S U PER IO R C O UR T O F C ALIF O RN IA , C O UNTY O FSTR EET A D DR ESSM AIL IN G A D D RESSC IT Y A N D Z IP C O DEBR AN CH N AM ESuperio r C ourt C ase N um berJ U DG ES ( a ll w ho p artic ip ate d in c a se ):N O TE T O A PPELLA NT: Y ou m ust f ile t h is f o rm w it h t h e c le rk o f t h e C ourt o f A ppeal w it h in 1 0 d ays a fte r t h e c le rk m ails y o u a n o tic e t h at t h is f o rm m ust b e f ile d . Y ou m ust a tta ch t o t h is f o rm ( 1 ) a c o py o f t h e j u dgm en t o r o rd er b ein g a p peale d t h at sh ow s t h e d ate i t w as e n te re d ( s ee C al. R ule s o f C ourt, r u le 8 .1 0 4 f o r d efin it io n o f ''e n te re d '') a n d ( 2 ) p ro of o f s erv ic e o f t h is fo rm o n a ll p artie s t o t h e a p peal. ( C AUTIO N: A n a p peal i n a l im it e d c iv il c ase ( C ode C iv . P ro c., § 8 5) m ay b e t a ken O NLY t o th e a p pella te d iv is io n o f t h e s u perio r c o urt ( C ode C iv . P ro c., § 9 0 4.2 ), o r t o t h e s u perio r c o urt ( C ode. C iv . P ro c., § 1 16.7 10 [sm all c la im s c ases]).A. APPEALABILITY 1. Appeal is from:PART I - APPEAL INFORMATIONJ u dgm ent a fte r ju ry t r ia l Judgm ent a fte r c o urt t r ia lD efa ult ju d gm entJu dgm ent a fte r a n o rd er g ra ntin g a s u m mary ju dgm ent m otio n Judgm ent o f d is m is sa l u nder C ode C iv . P ro c., § § 5 81 d , 5 83.2 50, 5 83.3 60, o r 5 83.4 30 Judgm ent o f d is m is sa l a fte r a n o rd er s u sta in in g a d em urre r An o rd er a fte r ju dgm ent u nder C od e C iv . P ro c., § 9 04.1 ( a )(2 ) An o rd er o r ju dgm ent u nder C ode C iv . P ro c., § 9 04.1 ( a )(3 )-(1 3) Oth er ( d e scrib e a nd s p ecif y c o de s e ctio n t h at a uth oriz e s t h is a ppeal) :2. Does the judgment Yesa ppeale d f r o m d is p ose o f a ll c a use s o f a ctio n, in clu din g a ll c ro ss-a ctio ns b etw een t h e p artie s? No If n o, p le ase e xp la in w hy t h e ju dgm ent is a ppeala ble :B. TIMELINESS OF APPEAL (Provide all applicable dates.)1 . D ate o f e ntr y o f ju dgm ent o r o rd er a ppeale d f r o m ://2. D ate t h at n otic e o f e ntr y o f ju dgm ent o r a c o py o f t h e ju dgm ent w as m aile d b y t h e c le rk o r s e rv e d b y a p arty u nder C alif o rn iaR ule s o f C ourt, 8 .1 04://3. W as a m otio n f o r n ew t r ia l, ju dgm ent n otw it h sta ndin g t h e v e rd ic t, r e co nsid era tio n, o r t o v a ca te t h e ju dgm ent m ade a nd d enie d?Y esNo If yes, please specify the type of motion:D ate m otio n f ile d://D ate d en ie d://D ate d en ia l s e rv e d ://4.D ate n otic e o fappealo rcro ss-a ppeal f ile d://C . B AN KR UPTC Y O R O TH ER S TA YIs t h ere a r e la te d b a nkru ptc y c a se o r a c o urt- o rd ere d s ta y t h at a ffe cts t h is a ppeal? a c o p y o f t h e b ankru ptc y p etit io n [ w it h out a tta ch m ents ] a nd a ny s ta y o rd er.Y esN oIf y e s, p le ase a tta chPage 1 o f 2F orm A dopte d fo r M andato ry U se Ju dic ia l C ouncil o f C alif o rn ia AP P-0 04 [R ev. J a nuary 1 , 2 007]C IV IL C A SE I N FO RM ATIO N S TA TE M EN Tele ctr o nic f o rm 2 004- 7 WWW.LawCA.com La w P ublis h ers P le ase a tt a ch t o t h is f o rm a lis t o f a ll t h e p artie s a nd a ll t h eir a tto rn eys o f r e co rd w ho w ill p artic ip ate in t h e a ppeal. F or t h e p artie s, in clu de t h e f o llo w in g in fo rm atio n: t h e p arty 's n am e a nd h is o r h er d esig natio n in t h e t r ia l c o urt p ro ce edin g ( p la in tif f, d efe ndant, e tc .) . F or the a tto rn eys, in clu de t h e f o llo w in g in fo rm atio n: n am e, S ta te B ar n um ber, m ailin g a ddre ss, t e le phone n um ber, f a x n um ber, a nd e -m ail ad dre ss.A PPELLA TE C ASE T IT LE :SU PER IO R C O URT C ASE N UM BERD .A PPELLA TE C ASE H IS TO RY ( P ro vid e a ddit io nal in fo rm atio n, if n ece ssa ty , o n a tta ch m ent I . D .) Is t h ere n ow , o r h as t h ere p re vio usly b een, a ny a ppeal, w rit , o r o th er p ro ce edin g r e la te d t o t h is c a se p endin g in a ny C alif o rn iaa ppella te c o urt?Y esNo If yes, insert name of appellate court:Appella te c o urt c a se n o.:T it le o f c a se :N am e o f t r ia l c o urt:T ria l c o urt c a se n o.:E. SERVICE REQUIREMENTS Is s e rv ic e o f d ocu m ents in t h is m atte r, in clu din g a b rie f o r a p etit io n r e quir e d o n t h e A tto rn ey G enera l o r o th er n onparty p ublic o ffic e ror a ge ncy u nder C alif o rn ia R ule s o f C ourt, r u le 8 .2 9 o r a s ta tu te ? sta tu te t h a t a pplie s.Y esN o I f y e s, p le ase in dic a te t h e r u le o rR ule 8 .2 9 Bus. & P ro f. C ode , § 1 7209 ( U nfa ir C om petit io n A ct) Bu s. & P ro f. C ode , § 1 7536.5 ( F als e a dve rtis in g) Civ . C ode, § 5 1.1 ( U nru h, R alp h, o r B ane C iv il Rig hts A cts -, a ntib oyco tt c a use o f a ctio n-, s e xu al hara ssm ent in b usin ess o r p ro fe ss io nal r e la tio ns-, civ il r ig hts a ctio n b y d is tr ic t a tto rn ey) Civ . C ode, § 5 5.2 ( D is a ble d a cce ss t o p ublic co nve ya nce s, a cc o m modatio ns, a nd h ousin g)G ov. C ode, § 4 461 ( D is a ble d a cce ss t o p ublic b uild in gs) Go v. C ode, § 1 2656(a ) ( F als e C la im s A ct)H ealt h & S af. C ode, § 1 9954.5 ( A cce ssib le s e atin g a ndacco m modatio ns)H ealt h & S af. C ode, § 1 9959.5 ( D is a ble d a cce ss t o pr iv a te ly f u nded p ublic a cco m moda tio ns) Oth er ( p le ase s p ecif y s ta tu te ):N O TE : T he r u le a nd s ta tu to ry p ro vis io ns lis te d a bove r e quir e s e rv ic e o f a c o py o f a p arty 's b rie f o r p etit io n a nd b rie f o n the A tto rn ey G enera l o r o th er p ublic o ffic e r o r a gency. O th er s ta tu te s r e quir in g s e rv ic e o n t h e A tto rn ey G enera l o r o th er public o ffic e rs o r a gencie s m ay a ls o a pply . ( S ee, e .g ., C ode C iv . P ro c., § 1 355; G ov. C ode, § 9 46.6 (d ); P ub. R eso urc e s Code, § 2 1167.7 .)P AR T 1 1 - N ATU RE O F A C TIO NA. N atu re o f a ctio n ( c h eck a ll t h at a pply ):1 .C onse rv a to rs h ip2 .C ontr a ct3.E m in ent d om ain4 .E quit a ble a ctio na.D ecla ra to ry r e lie fb.O th er ( d e scrib e):5 .F am ily la w6.G uard ia nsh ip7 .P ro bate8 .R eal p ro p erty r ig htsa .T it le o f r e al p ro perty b .O th er ( d e scrib e):9 .T orta .M edic a l m alp ra ctic eb .P ro duct lia b ilit yC.O th er p ers o nal in ju ryd .P ers o nal p ro pertye .O th er t o rt ( d escrib e):1 0.T ru st p ro ce edin gs11.W rit p ro ce edin gs in s u perio r c o urta .M andate ( C ode C iv . P ro c., § 1 085 ) Pro hib it io n ( C ode C iv . P ro c., § 1 102)b.C.d.A dm in is tr a tiv e m an date ( C ode C iv . P ro c., § 1 094.5 ) Oth er ( d e scrib e):1 2.O th er a ctio n ( d escrib e):B .This a ppea l is e ntit le d t o c a le ndar p re fe re nce /p rio rit y o n a ppeal ( c it e a uth orit y ):PART III - PARTY AND ATTORNEY INFORMATIONDate -T his s ta te m ent is p re pare d a nd s u b m it te d b y:(S IG NATU RE O F A TTO RNEY O R U NREPR ESEN TE D P AR TY )APP-0 04 [R ev. J a nuary 1 , 2 007]C IV IL C A SE I N FO RM ATIO N S TA TE M EN TPage 2 of 2

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