Frances Enyart v. County of San Bernardino ( 2023 )

1 Danielle R. Pena, Esq., SBN 286002 dpena@PHGLawGroup.com 2 PHG Law Group 501 West Broadway, Suite 1480 3 San Diego, CA. 92101 4 Telephone: (619) 826-8060 Facsimile: (619) 826-8065 5 LAW OFFICE OF SHARON J. BRUNNER 6 Sharon J. Brunner, Esq. (SBN: 229931) Email: sharonjbrunner@yahoo.com 7 14393 Park Avenue, Suite 100 Victorville, CA 92392 8 Tel: (760) 243-9997 Fax: (760) 843-8155 9 LAW OFFICE OF JAMES S. TERRELL 10 James S. Terrell, Esq. (SBN. 170409) 11 Email: jim@talkterrell.com 15411 Anacapa Road 12 Victorville, California 92392 Tel: (760) 951-5850 13 14 UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA 15 16 FRANCES ENYART, Individually, Case No.: 5:23-cv-00540-RGK-SHK and as Successor in Interest to 17 WILLIAM ENYART, GREGORY ENYART, as an individual, and 18 AMANDA KELLEY as STIPULATED PROTECTIVE GUARDIAN ADS LITEM TO ORDER1 19 A.E., 20 Plaintiffs, 21 v. 22 COUNTY OF SAN BERNARDINO, AARON 23 CONLEY, DEPUTY C. UMPHLETT, ROD SKAGGS, 24 DEPUTY SNOW, DEPUTY SILVA, and DOES 1-10, inclusive, 25 Defendants. 26 27 1 This Stipulated Protective Order is substantially based on the model protective order provided under Magistrate 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. Accordingly, the parties hereby stipulate to and petition the Court to 6 enter the following Stipulated Protective Order. The parties acknowledge that this 7 Order does not confer blanket protections on all disclosures or responses to 8 discovery and that the protection it affords from public disclosure and use extends 9 only to the limited information or items that are entitled to confidential treatment 10 under the applicable legal principles. 11 B. GOOD CAUSE STATEMENT 12 This action is likely to involve confidential, proprietary or private 13 information for which special protection from public disclosure and from use for 14 any purpose other than prosecution of this action is warranted. Such confidential, 15 proprietary and private materials and information consist of, among other things, 16 confidential and private information related to peace officers and 17 department policies including information otherwise generally unavailable to the 18 public, or which may be privileged or otherwise protected from disclosure under 19 state or federal statutes, court rules, case decisions, or common law. Accordingly, 20 to expedite the flow of information, to facilitate the prompt resolution of disputes 21 over confidentiality of discovery materials, to adequately protect information the 22 parties are entitled to keep confidential, to ensure that the parties are permitted 23 reasonable necessary uses of such material in preparation for and in the conduct of 24 trial, to address their handling at the end of the litigation, and serve the ends of 25 justice, a protective order for such information is justified in this matter. It is the 26 intent of the parties that information will not be designated as confidential for 27 tactical reasons and that nothing be so designated without a good faith belief that 1 it has been maintained in a confidential, non-public manner, and there is good 2 cause why it should not be part of the public record of this case. 3 C. ACKNOWLEDGEMENT OF PROCEDURE FOR FILING 4 UNDER SEAL 5 The parties further acknowledge, as set forth in Section 12.3, below, that 6 this Stipulated Protective Order does not entitle them to file confidential 7 information under seal; Local Civil Rule 79-5 sets forth the procedures that must 8 be followed and the standards that will be applied when a party seeks permission 9 from the court to file material under seal. 10 There is a strong presumption that the public has a right of access to 11 judicial proceedings and records in civil cases. In connection with non-dispositive 12 motions, good cause must be shown to support a filing under seal. See Kamakana 13 v. City and County of Honolulu, 447 F.3d 1172, 1176 (9th Cir. 2006); Phillips v. 14 Gen. Motors Corp., 307 F.3d 1206, 1210-11 (9th Cir. 2002); Makar-Welbon v. 15 Sony Electrics, Inc., 187 F.R.D. 576, 577 (E.D. Wis. 1999) (even stipulated 16 protective orders require good cause showing), and a specific showing of good 17 cause or compelling reasons with proper evidentiary support and legal 18 justification, must be made with respect to Protected Material that a party seeks to 19 file under seal. The parties’ mere designation of Disclosure or Discovery Material 20 as CONFIDENTIAL does not—without the submission of competent evidence by 21 declaration, establishing that the material sought to be filed under seal qualifies as 22 confidential, privileged, or otherwise protectable—constitute good cause. 23 Further, if a party requests sealing related to a dispositive motion or trial, 24 then compelling reasons, not only good cause, for the sealing must be shown, and 25 the relief sought shall be narrowly tailored to serve the specific interest to be 26 protected. See Pintos v. Pacific Creditors Ass’n, 605 F.3d 665, 677-79 (9th Cir. 27 2010). For each item or type of information, document, or thing sought to be filed 1 or introduced under seal in connection with a dispositive motion or trial, the party 2 seeking protection must articulate compelling reasons, supported by specific facts 3 and legal justification, for the requested sealing order. Again, competent evidence 4 supporting the application to file documents under seal must be provided by 5 declaration. 6 Any document that is not confidential, privileged, or otherwise protectable 7 in its entirety will not be filed under seal if the confidential portions can be 8 redacted. If documents can be redacted, then a redacted version for public 9 viewing, omitting only the confidential, privileged, or otherwise protectable 10 portions of the document shall be filed. Any application that seeks to file 11 documents under seal in their entirety should include an explanation of why 12 redaction is not feasible. 13 2. DEFINITIONS 14 2.1 Action: This pending federal lawsuit in Case number 5:23-cv-00540- 15 RGK-KK. 16 2.2 Challenging Party: A Party or Non-Party that challenges the 17 designation of information or items under this Order. 18 2.3 “CONFIDENTIAL” Information or Items: Information (regardless of 19 how it is generated, stored or maintained) or tangible things that qualify for 20 protection under Federal Rule of Civil Procedure 26(c), and as specified above in 21 the Good Cause Statement. 22 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as 23 their support staff). 24 2.5 Designating Party: A Party or Non-Party that designates information 25 or items that it produces in disclosures or in responses to discovery as 26 “CONFIDENTIAL.” 27 1 2.6 Disclosure or Discovery Material: All items or information, 2 regardless of the medium or manner in which it is generated, stored, or maintained, 3 that are produced or generated in disclosures or responses to discovery in this 4 matter. 5 2.7. Expert: A person with specialized knowledge or experience in a 6 matter pertinent to the litigation who has been retained by a Party or its counsel to 7 serve as an expert witness or as a consultant in this Action. 8 2.8 House Counsel: County Counsel including his or her staff. 9 2.9 Non-Party: Any natural person including employees and former 10 employees, agency, partnership, corporation, association, or other legal entity not 11 named as a Party to this action. 12 2.10 Outside Counsel of Record: Attorneys who are retained to represent 13 or advise a party to this Action and have appeared in this Action on behalf of that 14 party or are affiliated with a law firm which has appeared on behalf of that party 15 and includes support staff. 16 2.11 Party: Any party to this Action, including all of its officers, directors, 17 employees, consultants, retained experts, and Outside Counsel of Record and 18 House Counsel (and their support staff). 19 2.12 Producing Party: A Party or Non-Party that produces Disclosure or 20 Discovery Material in this Action. 21 2.13 Professional Vendors: Persons or entities that provide litigation 22 support services (e.g., photocopying, videotaping, translating, preparing exhibits 23 or demonstrations, and organizing, storing, or retrieving data in any form or 24 medium) and their employees and subcontractors. 25 2.14 Protected Material: Any Disclosure or Discovery Material that is 26 designated as “CONFIDENTIAL.” 27 1 2.15 Receiving Party: A Party that receives Disclosure or Discovery 2 Material from a Producing Party. 3 3. SCOPE 4 The protections conferred by this Stipulation and Order cover not only 5 Protected Material (as defined above), but also (1) any information copied or 6 Extracted from Protected Material; (2) all copies, excerpts, summaries, or 7 compilations of Protected Material; and (3) any testimony, conversations, or 8 presentations by Parties or their Counsel that might reveal Protected Material. 9 Any use of Protected Material at trial shall be governed by the orders of 10 the trial judge. This Order does not govern the use of Protected Material at trial. 11 4. DURATION 12 Once a case proceeds to trial, information that was designated as 13 CONFIDENTIAL or maintained pursuant to this protective order used or 14 introduced as an exhibit at trial becomes public and will be presumptively 15 available to all members of the public, including the press, unless compelling 16 reasons supported by specific factual findings to proceed otherwise are made to 17 the trial judge in advance of the trial. See Kamakana, 447 F.3d at 1180-81 18 (distinguishing “good cause” showing for sealing documents produced in 19 discovery from “compelling reasons” standard when merits-related documents are 20 part of court record). Accordingly, the terms of this protective order do not extend 21 beyond the commencement of the trial. 22 5. DESIGNATING PROTECTED MATERIAL 23 5.1 Exercise of Restraint and Care in Designating Material for 24 Protection. Each Party or Non-Party that designates information or items 25 for protection under this Order must take care to limit any such designation to 26 specific material that qualifies under the appropriate standards. The Designating 27 Party must designate for protection only those parts of material, documents, items, 1 or oral or written communications that qualify so that other portions of the 2 material, documents, items, or communications for which protection is not 3 warranted are not swept unjustifiably within the ambit of this Order. 4 Mass, indiscriminate, or routinized designations are prohibited. 5 Designations that are shown to be clearly unjustified or that have been made for 6 an improper purpose (e.g., to unnecessarily encumber the case development 7 process or to impose unnecessary expenses and burdens on other parties) may 8 expose the Designating Party to sanctions. 9 If it comes to a Designating Party’s attention that information or items that 10 it designated for protection do not qualify for protection, that Designating Party 11 must promptly notify all other Parties that it is withdrawing the inapplicable 12 designation. 13 5.2 Manner and Timing of Designations. Except as otherwise provided in 14 this Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise 15 stipulated or ordered, Disclosure or Discovery Material that qualifies for 16 protection under this Order must be clearly so designated before the material is 17 disclosed or produced. 18 Designation in conformity with this Order requires: 19 (a) For information in documentary form (e.g., paper or electronic 20 documents, but excluding transcripts of depositions or other pretrial or trial 21 proceedings), that the Producing Party affix at a minimum, the legend 22 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 23 contains protected material. If only a portion or portions of the material on a page 24 qualifies for protection, the Producing Party also must clearly identify the 25 protected portion(s) (e.g., by making appropriate markings in the margins). 26 A Party or Non-Party that makes original documents available for 27 inspection need not designate them for protection until after the inspecting Party 1 has indicated which documents it would like copied and produced. During the 2 inspection and before the designation, all of the material made available for 3 inspection shall be deemed “CONFIDENTIAL.” After the inspecting Party has 4 identified the documents, it wants copied and produced, the Producing Party must 5 determine which documents, or portions thereof, qualify for protection under this 6 Order. Then, before producing the specified documents, the Producing Party must 7 affix the “CONFIDENTIAL legend” to each page that contains Protected Material. 8 If only a portion or portions of the material on a page qualifies for protection, the 9 Producing Party also must clearly identify the protected portion(s) (e.g., by making 10 appropriate markings in the margins). 11 (b) For testimony given in depositions that the Designating Party 12 identify the Disclosure or Discovery Material on the record, before the close of the 13 deposition all protected testimony. 14 (c) For information produced in some form other than 15 documentary and for any other tangible items, that the Producing Party affix in a 16 prominent place on the exterior of the container or containers in which the 17 information is stored the legend “CONFIDENTIAL.” If only a portion or portions 18 of the information warrants protection, the Producing Party, to the extent 19 practicable, shall identify the protected portion(s). 20 5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 21 failure to designate qualified information or items does not, standing alone, waive 22 the Designating Party’s right to secure protection under this Order for such 23 material. Upon timely correction of a designation, the Receiving Party must make 24 reasonable efforts to assure that the material is treated in accordance with the 25 provisions of this Order. 26 27 1 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 2 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 3 designation of confidentiality at any time that is consistent with the Court’s 4 Scheduling Order. 5 6.2 Meet and Confer. The Challenging Party shall initiate the dispute 6 resolution process under Local Rule 37.1 et seq. 7 6.3 The burden of persuasion in any such challenge proceeding shall be 8 on the Designating Party. Frivolous challenges, and those made for an improper 9 purpose (e.g., to harass or impose unnecessary expenses and burdens on other 10 parties) may expose the Challenging Party to sanctions. Unless the Designating 11 Party has waived or withdrawn the confidentiality designation, all parties shall 12 continue to afford the material in question the level of protection to which it is 13 entitled under the Producing Party’s designation until the Court rules on the 14 challenge. 15 7. ACCESS TO AND USE OF PROTECTED MATERIAL 16 7.1 Basic Principles. A Receiving Party may use Protected Material that 17 is disclosed or produced by another Party or by a Non-Party in connection with 18 this Action only for prosecuting, defending, or attempting to settle this Action. 19 Such Protected Material may be disclosed only to the categories of persons and 20 under the conditions described in this Order. When the Action has been terminated, 21 a Receiving Party must comply with the provisions of Section 13 below (FINAL 22 DISPOSITION). 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 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 27 otherwise ordered by the Court or permitted in writing by the Designating Party, a 1 Receiving Party may disclose any information or item designated 2 “CONFIDENTIAL” only to: 3 (a) The Receiving Party’s Outside Counsel of Record in this 4 Action, as well as employees of said Outside Counsel of Record to whom it is 5 reasonably necessary to disclose the information for this Action; 6 (b) The officers, directors, and employees (including House 7 Counsel) of the Receiving Party to whom disclosure is reasonably necessary for 8 this Action; 9 (c) Experts (as defined in this Order) of the Receiving Party to 10 whom disclosure is reasonably necessary for this Action and who have signed the 11 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 12 (d) The Court and its personnel; 13 (e) Court reporters and their staff; 14 (f) Professional jury or trial consultants, mock jurors, and 15 Professional Vendors to whom disclosure is reasonably necessary for this Action 16 and who have signed the “Acknowledgment and Agreement to Be Bound” 17 (Exhibit A); 18 (g) The author or recipient of a document containing the 19 information or a custodian or other person who otherwise possessed or knew the 20 information; 21 (h) During their depositions, witnesses, and attorneys for 22 witnesses, in the Action to whom disclosure is reasonably necessary provided: (1) 23 the deposing party requests that the witness sign the form attached as Exhibit 1 24 hereto; and (2) they will not be permitted to keep any confidential information 25 unless they sign the “Acknowledgment and Agreement to Be Bound” (Exhibit A), 26 unless otherwise agreed by the Designating Party or ordered by the Court. Pages 27 of transcribed deposition testimony or exhibits to depositions that reveal Protected 1 Material may be separately bound by the court reporter and may not be disclosed 2 to anyone except as permitted under this Stipulated Protective Order; and 3 (i) Any mediator or settlement officer, and their supporting 4 personnel, mutually agreed upon by any of the parties engaged in settlement 5 discussions. 6 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED 7 PRODUCED IN OTHER LITIGATION 8 If a Party is served with a subpoena or a court order issued in other litigation 9 that compels disclosure of any information or items designated in this Action as 10 “CONFIDENTIAL,” that Party must: 11 (a) Promptly notify in writing the Designating Party. Such notification 12 shall include a copy of the subpoena or court order; 13 (b) Promptly notify in writing the party who caused the subpoena or order 14 to issue in the other litigation that some or all of the material covered by the 15 subpoena or order is subject to this Protective Order. Such notification shall 16 include a copy of this Stipulated Protective Order; and 17 (c) Cooperate with respect to all reasonable procedures sought to be 18 pursued by the Designating Party whose Protected Material may be affected. 19 If the Designating Party timely seeks a protective order, the Party served 20 with the subpoena or court order shall not produce any information designated in 21 this action as “CONFIDENTIAL” before a determination by the court from which 22 the subpoena or order issued, unless the Party has obtained the Designating Party’s 23 permission. The Designating Party shall bear the burden and expense of seeking 24 protection in that court of its confidential material and nothing in these provisions 25 should be construed as authorizing or encouraging a Receiving Party in this Action 26 to disobey a lawful directive from another court. 27 /// 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 Stipulated 16 Protective Order in this Action, the relevant discovery request(s), and a reasonably 17 specific description of the information requested; and 18 (3) Make the information requested available for inspection by the 19 Non-Party, if requested. 20 (c) If the Non-Party fails to seek a protective order from this court within 21 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 25 to 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 27 and 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 3 disclosed Protected Material to any person or in any circumstance not authorized 4 under this Stipulated Protective Order, the Receiving Party must immediately (a) 5 notify in writing the Designating Party of the unauthorized disclosures, (b) use its 6 best efforts to retrieve all unauthorized copies of the Protected Material, (c) inform 7 the person or persons to whom unauthorized disclosures were made of all the terms 8 of this Order, and (d) request such person or persons to execute the 9 “Acknowledgment and Agreement to Be Bound” that is attached hereto as Exhibit 10 A. 11 11. INADVERTENT PRODUCTION OF PRIVILEGED OR 12 OTHERWISE PROTECTED MATERIAL 13 When a Producing Party gives notice to Receiving Parties that certain 14 inadvertently produced material is subject to a claim of privilege or other 15 protection, the obligations of the Receiving Parties are those set forth in Federal 16 Rule of Civil Procedure 26(b)(5)(B). This provision is not intended to modify 17 whatever procedure may be established in an e-discovery order that provides for 18 production without prior privilege review. Pursuant to Federal Rule of Evidence 19 502(d) and (e), insofar as the parties reach an agreement on the effect of disclosure 20 of a communication or information covered by the attorney-client privilege or 21 work product protection, the parties may incorporate their agreement in the 22 Stipulated Protective Order submitted to the Court. 23 12. MISCELLANEOUS 24 12.1 Right to Further Relief. Nothing in this Order abridges the right of 25 any person to seek its modification by the Court in the future. 26 12.2 Right to Assert Other Objections. By stipulating to the entry of this 27 Protective Order, no Party waives any right it otherwise would have to object to 1 disclosing or producing any information or item on any ground not addressed in 2 this Stipulated Protective Order. Similarly, no Party waives any right to object on 3 any ground to use in evidence of any of the material covered by this Protective 4 Order. 5 12.3 Filing Protected Material. A Party that seeks to file under seal any 6 Protected Material must comply with Civil Local Rule 79-5. Protected Material 7 may only be filed under seal pursuant to a court order authorizing the sealing of 8 the specific Protected Material at issue. If a Party's request to file Protected 9 Material under seal is denied by the court, then the Receiving Party may file the 10 information in the public record unless otherwise instructed by the Court. 11 13. FINAL DISPOSITION 12 After the final disposition of this Action, as defined in Section 4, within 13 sixty (60) days of a written request by the Designating Party, each Receiving Party 14 must return all Protected Material to the Producing Party or destroy such material. 15 As used in this subdivision, “all Protected Material” includes all copies, abstracts, 16 compilations, summaries, and any other format reproducing or capturing any of 17 the Protected Material. Whether the Protected Material is returned or destroyed, 18 the Receiving Party must submit a written certification to the Producing Party 19 (and, if not the same person or entity, to the Designating Party) by the 60 day 20 deadline that (1) identifies (by category, where appropriate) all the Protected 21 Material that was returned or destroyed and (2) affirms that the Receiving Party 22 has not retained any copies, abstracts, compilations, summaries or any other format 23 reproducing or capturing any of the Protected Material. Notwithstanding this 24 provision, Counsel are entitled to retain an archival copy of all pleadings, motion 25 papers, trial, deposition, and hearing transcripts, legal memoranda, 26 correspondence, deposition and trial exhibits, expert reports, attorney work 27 product, and consultant and expert work product, even if such materials contain 1 Protected Material. Any such archival copies that contain or constitute Protected 2 Material remain subject to this Protective Order as set forth in Section 4 3 (DURATION). 4 /// 5 /// 6 /// 7 /// 8 /// 9 /// 10 /// 11 /// 12 /// 13 /// 14 /// 15 /// 16 /// 17 /// 18 /// 19 /// 20 /// 21 /// 22 /// 23 /// 24 /// 25 /// 26 /// 27 /// 1 | 14. VIOLATION 2 Any violation of this Order may be punished by any and all appropriate 3 || measures including, without limitation, contempt proceedings and/or monetary 4 || sanctions. 5 6 | ITISSO STIPULATED, THROUGH COUNSEL OF RECORD. 7 g || DATED: November 22, 202 /s/DanielleR. Pena Danielle R. Pena, Esq. 9 James S. Terrell, Esq. 10 Sharon J. Brunner, Esq. Attorneys for Plaintiffs 11 12 13 || DATED: November 22, 2023 /s/ Jacob M. Ramirez 14 Jacob M. Ramirez, Esq. Deputy County Counsel 15 Attorney for Defendants 16 17 FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. 18 Tt DATED: 12/27/2023 Nyse 20 HONORABLE SHASHI H. KEWALRAMANI United States Magistrate Judge 21 22 23 24 25 26 27 28 16 CASE NO 5:23-cv-00540-RGK-KK 1 2 EXHIBIT A 3 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND 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 issue by the United States District Court for the Central District of California 8 on ____________ [Date] in the case of xy. I agree to comply with and to be 9 bound by all the terms of this Stipulated Protective Order and I understand and 10 acknowledge that failure to so comply could expose me to sanctions and 11 punishment in the nature of contempt. I solemnly promise that I will not disclose 12 in any manner any information or item that is subject to this Stipulated Protective 13 Order to any person or entity except in strict compliance with the provisions of 14 this Order. 15 I further agree to submit to the jurisdiction of the United States District 16 Court for the Central District of California for the purpose of enforcing the terms 17 of this Stipulated Protective Order, even if such enforcement proceedings occur 18 after termination of this action. I hereby appoint 19 [print or type full name] of [print or type full 20 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 Printed Name: 26 Signature: 27