Paloma Bell v. Chris Jones ( 2019 )

MICHAEL N. FEUER, City Attorney 1 KATHLEEN A. KENEALY, Chief Assistant City Attorney (SBN 212289) SCOTT MARCUS, Chief, Civil Litigation Branch (SBN 184980) 2 CORY M. BRENTE, Senior Assistant City Attorney (SBN 115453) GEOFFREY PLOWDEN, Deputy City Attorney - (SBN 146602) 3 200 N. Main Street, 6th Floor City Hall East Los Angeles, California 90012 4 E-mail: geoffrey.plowden@lacity.org Phone: (213) 978-7038 Fax No. (213) 978-8785 5 6 Attorneys for Defendants CITY OF LOS ANGELES 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 PALOMA BELL, an individual; Case No.: CV 19-06886FMO(AGR) MICHAEL COSCHIGANO, an District Judge: Hon. Fernando M. Olguin 12 individual, Magistrate Judge: Hon. Alice G. Rosenberg 13 Plaintiffs, v. STIPULATED PROTECTIVE 14 ORDER CHRIS JONES, #39399, individually and 15 as a peace officer; ALVIN MARQUES, Complaint Filed: 0110/2019 #39005, individually and as a peace 16 officer; CITY OF LOS ANGELES; and, Trial Date: 6/9/2020 17 DOES 1-50, inclusive, 18 Defendants. 19 20 1. A. PURPOSES AND LIMITATIONS 21 Discovery in this action is likely to involve production of confidential, 22 proprietary or private information for which special protection from public disclosure 23 and from use for any purpose other than prosecuting this litigation may be warranted. 24 Accordingly, the parties hereby stipulate to and petition the Court to enter the following 25 Stipulated Protective Order. The parties acknowledge that this Order does not confer 26 blanket protections on all disclosures or responses to discovery and that the protection 27 it affords from public disclosure and use extends only to the limited information or 28 items that are entitled to confidential treatment under the applicable legal principles. 1 B. GOOD CAUSE STATEMENT 2 This action is likely to involve third party privacy, HIPPA information, peace 3 officer personnel and official information for which special protection from public 4 disclosure and from use for any purpose other than prosecution of this action is 5 warranted. Such confidential and proprietary materials and information consist of, 6 among other things, (including information implicating privacy rights of third parties), 7 information otherwise generally unavailable to the public, or which may be privileged 8 or otherwise protected from disclosure under state or federal statutes, court rules, case 9 decisions, or common law. Accordingly, to expedite the flow of information, to 10 facilitate the prompt resolution of disputes over confidentiality of discovery materials, 11 to adequately protect information the parties are entitled to keep confidential, to ensure 12 that the parties are permitted reasonable necessary uses of such material in preparation 13 for and in the conduct of trial, to address their handling at the end of the litigation, and 14 serve the ends of justice, a protective order for such information is justified in this 15 matter. It is the intent of the parties that information will not be designated as 16 confidential for tactical reasons and that nothing be so designated without a good faith 17 belief that it has been maintained in a confidential, non-public manner, and there is good 18 cause why it should not be part of the public record of this case. 19 C. ACKNOWLEDGMENT OF PROCEDURE FOR FILING UNDER SEAL 20 The parties further acknowledge, as set forth in Section 12.3, below, that this 21 Stipulated Protective Order does not entitle them to file confidential information under 22 seal; Local Civil Rule 79-5 sets forth the procedures that must be followed and the 23 standards that will be applied when a party seeks permission from the court to file 24 material under seal. 25 There is a strong presumption that the public has a right of access to judicial 26 proceedings and records in civil cases. In connection with non-dispositive motions, 27 good cause must be shown to support a filing under seal. See Kamakana v. City and 28 County of Honolulu, 447 F.3d 1172, 1176 (9th Cir. 2006), Phillips v. Gen. Motors 1 Corp., 307 F.3d 1206, 1210-11 (9th Cir. 2002), Makar-Welbon v. Sony Electrics, Inc., 2 187 F.R.D. 576, 577 (E.D. Wis. 1999) (even stipulated protective orders require good 3 cause showing), and a specific showing of good cause or compelling reasons with 4 proper evidentiary support and legal justification, must be made with respect to 5 Protected Material that a party seeks to file under seal. The parties’ mere designation 6 of Disclosure or Discovery Material as CONFIDENTIAL does not—without the 7 submission of competent evidence by declaration, establishing that the material sought 8 to be filed under seal qualifies as confidential, privileged, or otherwise protectable— 9 constitute good cause. 10 Further, if a party requests sealing related to a dispositive motion or trial, then 11 compelling reasons, not only good cause, for the sealing must be shown, and the relief 12 sought shall be narrowly tailored to serve the specific interest to be protected. See 13 Pintos v. Pacific Creditors Ass’n, 605 F.3d 665, 677-79 (9th Cir. 2010). For each item 14 or type of information, document, or thing sought to be filed or introduced under seal 15 in connection with a dispositive motion or trial, the party seeking protection must 16 articulate compelling reasons, supported by specific facts and legal justification, for the 17 requested sealing order. Again, competent evidence supporting the application to file 18 documents under seal must be provided by declaration. 19 Any document that is not confidential, privileged, or otherwise protectable in its 20 entirety will not be filed under seal if the confidential portions can be redacted. If 21 documents can be redacted, then a redacted version for public viewing, omitting only 22 the confidential, privileged, or otherwise protectable portions of the document, shall be 23 filed. Any application that seeks to file documents under seal in their entirety should 24 include an explanation of why redaction is not feasible. 25 2. DEFINITIONS 26 2.1 Action: this pending federal lawsuit. 27 2.2 Challenging Party: a Party or Non-Party that challenges the designation 28 of information or items under this Order. 1 2.3 “CONFIDENTIAL” Information or Items: information (regardless of how 2 it is generated, stored or maintained) or tangible things that qualify for protection under 3 Federal Rule of Civil Procedure 26(c), and as specified above in the Good Cause 4 Statement. 5 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as their 6 support staff). 7 2.5 Designating Party: a Party or Non-Party that designates information or 8 items that it produces in disclosures or in responses to discovery as 9 “CONFIDENTIAL.” 10 2.6 Disclosure or Discovery Material: all items or information, regardless of 11 the medium or manner in which it is generated, stored, or maintained (including, among 12 other things, testimony, transcripts, and tangible things), that are produced or generated 13 in disclosures or responses to discovery in this matter. 14 2.7 Expert: a person with specialized knowledge or experience in a matter 15 pertinent to the litigation who has been retained by a Party or its counsel to serve as an 16 expert witness or as a consultant in this Action. 17 2.8 House Counsel: attorneys who are employees of a party to this Action. 18 House Counsel does not include Outside Counsel of Record or any other outside 19 counsel. 20 2.9 Non-Party: any natural person, partnership, corporation, association or 21 other legal entity not named as a Party to this action. 22 2.10 Outside Counsel of Record: attorneys who are not employees of a party 23 to this Action but are retained to represent or advise a party to this Action and have 24 appeared in this Action on behalf of that party or are affiliated with a law firm that has 25 appeared on behalf of that party, and includes support staff. 26 2.11 Party: any party to this Action, including all of its officers, directors, 27 employees, consultants, retained experts, and Outside Counsel of Record (and their 28 support staffs). 1 2.12 Producing Party: a Party or Non-Party that produces Disclosure or 2 Discovery Material in this Action. 3 2.13 Professional Vendors: persons or entities that provide litigation support 4 services (e.g., photocopying, videotaping, translating, preparing exhibits or 5 demonstrations, and organizing, storing, or retrieving data in any form or medium) and 6 their employees and subcontractors. 7 2.14 Protected Material: any Disclosure or Discovery Material that is 8 designated as “CONFIDENTIAL.” A watermark may be affixed to the documents. 9 2.15 Receiving Party: a Party that receives Disclosure or Discovery Material 10 from a Producing Party. 11 3. SCOPE 12 The protections conferred by this Stipulation and Order cover not only Protected 13 Material (as defined above), but also (1) any information copied or extracted from 14 Protected Material; (2) all copies, excerpts, summaries, or compilations of Protected 15 Material; and (3) any testimony, conversations, or presentations by Parties or their 16 Counsel that might reveal Protected Material. 17 Any use of Protected Material at trial shall be governed by the orders of the trial 18 judge. This Order does not govern the use of Protected Material at trial. 19 4. DURATION 20 Once a case proceeds to trial, information that was designated as 21 CONFIDENTIAL or maintained pursuant to this protective order used or introduced as 22 an exhibit at trial becomes public and will be presumptively available to all members 23 of the public, including the press, unless compelling reasons supported by specific 24 factual findings to proceed otherwise are made to the trial judge in advance of the trial. 25 See Kamakana, 447 F.3d at 1180-81 (distinguishing “good cause” showing for sealing 26 documents produced in discovery from “compelling reasons” standard when merits- 27 related documents are part of court record). Accordingly, the terms of this protective 28 order do not extend beyond the commencement of the trial. 1 5. DESIGNATING PROTECTED MATERIAL 2 5.1 Exercise of Restraint and Care in Designating Material for Protection. 3 Each Party or Non-Party that designates information or items for protection under this 4 Order must take care to limit any such designation to specific material that qualifies 5 under the appropriate standards. The Designating Party must designate for protection 6 only those parts of material, documents, items or oral or written communications that 7 qualify so that other portions of the material, documents, items or communications for 8 which protection is not warranted are not swept unjustifiably within the ambit of this 9 Order. 10 Mass, indiscriminate or routinized designations are prohibited. Designations that 11 are shown to be clearly unjustified or that have been made for an improper purpose 12 (e.g., to unnecessarily encumber the case development process or to impose 13 unnecessary expenses and burdens on other parties) may expose the Designating Party 14 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 5.2 Manner and Timing of Designations. Except as otherwise provided in this 19 Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise stipulated 20 or ordered, Disclosure or Discovery Material that qualifies for protection under this 21 Order must be clearly so designated before the material is disclosed or produced. 22 Designation in conformity with this Order requires: 23 (a) for information in documentary form (e.g., paper or electronic documents, 24 but excluding transcripts of depositions or other pretrial or trial proceedings), that the 25 Producing Party affix at a minimum, the legend “CONFIDENTIAL” (hereinafter 26 “CONFIDENTIAL legend”), to each page that contains protected material. If only a 27 portion of the material on a page qualifies for protection, the Producing Party also must 28 clearly identify the protected portion(s) (e.g., by making appropriate markings in the 1 margins). 2 A Party or Non-Party that makes original documents available for inspection 3 need not designate them for protection until after the inspecting Party has indicated 4 which documents it would like copied and produced. During the inspection and before 5 the designation, all of the material made available for inspection shall be deemed 6 “CONFIDENTIAL.” After the inspecting Party has identified the documents it wants 7 copied and produced, the Producing Party must determine which documents, or 8 portions thereof, qualify for protection under this Order. Then, before producing the 9 specified documents, the Producing Party must affix the “CONFIDENTIAL legend” to 10 each page that contains Protected Material. If only a portion of the material on a page 11 qualifies for protection, the Producing Party also must clearly identify the protected 12 portion(s) (e.g., by making appropriate markings in the margins). 13 (b) for testimony given in depositions that the Designating Party identifies 14 the Disclosure or Discovery Material on the record, before the close of the deposition 15 all protected testimony. 16 (c) for information produced in some form other than documentary and for 17 any other tangible items, that the Producing Party affix in a prominent place on the 18 exterior of the container or containers in which the information is stored the legend 19 “CONFIDENTIAL.” If only a portion or portions of the information warrants 20 protection, the Producing Party, to the extent practicable, shall identify the protected 21 portion(s). 22 5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 23 failure to designate qualified information or items does not, standing alone, waive the 24 Designating Party’s right to secure protection under this Order for such material. Upon 25 timely correction of a designation, the Receiving Party must make reasonable efforts to 26 assure that the material is treated in accordance with the provisions of this Order. 27 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 28 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 1 designation of confidentiality at any time that is consistent with the Court’s Scheduling 2 Order. 3 6.2 Meet and Confer. The Challenging Party shall initiate the dispute 4 resolution process under Local Rule 37.1 et seq. 5 6.3 The burden of persuasion in any such challenge proceeding shall be on the 6 Designating Party. Frivolous challenges, and those made for an improper purpose (e.g., 7 to harass or impose unnecessary expenses and burdens on other parties) may expose the 8 Challenging Party to sanctions. Unless the Designating Party has waived or withdrawn 9 the confidentiality designation, all parties shall continue to afford the material in 10 question the level of protection to which it is entitled under the Producing Party’s 11 designation until the Court rules on the challenge. 12 7. ACCESS TO AND USE OF PROTECTED MATERIAL 13 7.1 Basic Principles. A Receiving Party may use Protected Material that is 14 disclosed or produced by another Party or by a Non-Party in connection with this Action 15 only for prosecuting, defending or attempting to settle this Action. Such Protected 16 Material may be disclosed only to the categories of persons and under the conditions 17 described in this Order. When the Action has been terminated, a Receiving Party must 18 comply with the provisions of section 13 below (FINAL DISPOSITION). 19 Protected Material must be stored and maintained by a Receiving Party at a 20 location and in a secure manner that ensures that access is limited to the persons 21 authorized under this Order. 22 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 23 otherwise ordered by the court or permitted in writing by the Designating Party, a 24 Receiving Party may disclose any information or item designated “CONFIDENTIAL” 25 only to: 26 (a) the Receiving Party’s Outside Counsel of Record in this Action, as well 27 as employees of said Outside Counsel of Record to whom it is reasonably necessary to 28 disclose the information for this Action; 1 (b) the officers, directors, and employees (including House Counsel) of the 2 Receiving Party to whom disclosure is reasonably necessary for this Action; 3 (c) Experts (as defined in this Order) of the Receiving Party to whom 4 disclosure is reasonably necessary for this Action and who have signed the 5 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 6 (d) the court and its personnel; 7 (e) court reporters and their staff; 8 (f) professional jury or trial consultants, mock jurors, and Professional 9 Vendors to whom disclosure is reasonably necessary for this Action and who have 10 signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A); 11 (g) the author or recipient of a document containing the information or a 12 custodian or other person who otherwise possessed or knew the information; 13 (h) during their depositions, witnesses, and attorneys for witnesses, in the 14 Action to whom disclosure is reasonably necessary provided: (1) the deposing party 15 requests that the witness sign the form attached as Exhibit A hereto; and (2) they will 16 not be permitted to keep any confidential information unless they sign the 17 “Acknowledgment and Agreement to Be Bound” (Exhibit A), unless otherwise agreed 18 by the Designating Party or ordered by the court. Pages of transcribed deposition 19 testimony or exhibits to depositions that reveal Protected Material may be separately 20 bound by the court reporter and may not be disclosed to anyone except as permitted 21 under this Stipulated Protective Order; and 22 (i) any mediator or settlement officer, and their supporting personnel, 23 mutually agreed upon by any of the parties engaged in settlement discussions. 24 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED IN 25 OTHER LITIGATION 26 If a Party is served with a subpoena or a court order issued in other litigation that 27 compels disclosure of any information or items designated in this Action as 28 “CONFIDENTIAL,” that Party must: 1 (a) promptly notify in writing the Designating Party. Such notification shall 2 include a copy of the subpoena or court order; 3 (b) promptly notify in writing the party who caused the subpoena or order to 4 issue in the other litigation that some or all of the material covered by the subpoena or 5 order is subject to this Protective Order. Such notification shall include a copy of this 6 Stipulated Protective Order; and 7 (c) cooperate with respect to all reasonable procedures sought to be pursued 8 by the Designating Party whose Protected Material may be affected. 9 If the Designating Party timely seeks a protective order, the Party served with the 10 subpoena or court order shall not produce any information designated in this action as 11 “CONFIDENTIAL” before a determination by the court from which the subpoena or 12 order issued, unless the Party has obtained the Designating Party’s permission. The 13 Designating Party shall bear the burden and expense of seeking protection in that court 14 of its confidential material and nothing in these provisions should be construed as 15 authorizing or encouraging a Receiving Party in this Action to disobey a lawful 16 directive from another court. 17 9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE PRODUCED 18 IN THIS LITIGATION 19 (a) The terms of this Order are applicable to information produced by a Non- 20 Party in this Action and designated as “CONFIDENTIAL.” Such information produced 21 by Non-Parties in connection with this litigation is protected by the remedies and relief 22 provided by this Order. Nothing in these provisions should be construed as prohibiting 23 a Non-Party from seeking additional protections. 24 (b) In the event that a Party is required, by a valid discovery request, to 25 produce a Non-Party’s confidential information in its possession, and the Party is 26 subject to an agreement with the Non-Party not to produce the Non-Party’s confidential 27 information, then the Party shall: 28 (1) promptly notify in writing the Requesting Party and the Non-Party that 1 some or all of the information requested is subject to a confidentiality agreement with 2 a Non-Party; 3 (2) promptly provide the Non-Party with a copy of the Stipulated 4 Protective Order in this Action, the relevant discovery request(s), and a reasonably 5 specific description of the information requested; and 6 (3) make the information requested available for inspection by the Non- 7 Party, if requested. 8 (c) If the Non-Party fails to seek a protective order from this court within 14 9 days of receiving the notice and accompanying information, the Receiving Party may 10 produce the Non-Party’s confidential information responsive to the discovery request. 11 If the Non-Party timely seeks a protective order, the Receiving Party shall not produce 12 any information in its possession or control that is subject to the confidentiality 13 agreement with the Non-Party before a determination by the court. Absent a court order 14 to the contrary, the Non-Party shall bear the burden and expense of seeking protection 15 in this court of its Protected Material. 16 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 17 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 18 Protected Material to any person or in any circumstance not authorized under this 19 Stipulated Protective Order, the Receiving Party must immediately (a) notify in writing 20 the Designating Party of the unauthorized disclosures, (b) use its best efforts to retrieve 21 all unauthorized copies of the Protected Material, (c) inform the person or persons to 22 whom unauthorized disclosures were made of all the terms of this Order, and (d) request 23 such person or persons to execute the “Acknowledgment and Agreement to Be Bound” 24 that is attached hereto as Exhibit A. 11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 25 PROTECTED MATERIAL 26 When a Producing Party gives notice to Receiving Parties that certain 27 inadvertently produced material is subject to a claim of privilege or other protection, 28 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 1 Procedure 26(b)(5)(B). This provision is not intended to modify whatever procedure 2 may be established in an e-discovery order that provides for production without prior 3 privilege review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the 4 parties reach an agreement on the effect of disclosure of a communication or 5 information covered by the attorney-client privilege or work product protection, the 6 parties may incorporate their agreement in the stipulated protective order submitted to 7 the court. 8 12. MISCELLANEOUS 9 12.1 Right to Further Relief. Nothing in this Order abridges the right of any 10 person to seek its modification by the Court in the future. 11 12.2 Right to Assert Other Objections. By stipulating to the entry of this 12 Protective Order, no Party waives any right it otherwise would have to object to 13 disclosing or producing any information or item on any ground not addressed in this 14 Stipulated Protective Order. Similarly, no Party waives any right to object on any 15 ground to use in evidence of any of the material covered by this Protective Order. 16 12.3 Filing Protected Material. A Party that seeks to file under seal any 17 Protected Material must comply with Local Civil Rule 79-5. Protected Material may 18 only be filed under seal pursuant to a court order authorizing the sealing of the specific 19 Protected Material at issue. If a Party’s request to file Protected Material under seal is 20 denied by the court, then the Receiving Party may file the information in the public 21 record unless otherwise instructed by the court. 22 13. FINAL DISPOSITION 23 After the final disposition of this Action, as defined in paragraph 4, within 60 24 days of a written request by the Designating Party, each Receiving Party must return all 25 Protected Material to the Producing Party or destroy such material. As used in this 26 subdivision, “all Protected Material” includes all copies, abstracts, compilations, 27 summaries, and any other format reproducing or capturing any of the Protected 28 Material. Whether the Protected Material is returned or destroyed, the Receiving Party 1 must submit a written certification to the Producing Party (and, if not the same person 2 or entity, to the Designating Party) by the 60 day deadline that (1) identifies (by 3 category, where appropriate) all the Protected Material that was returned or destroyed 4 and (2) affirms that the Receiving Party has not retained any copies, abstracts, 5 compilations, summaries or any other format reproducing or capturing any of the 6 Protected Material. Notwithstanding this provision, Counsel are entitled to retain an 7 archival copy of all pleadings, motion papers, trial, deposition, and hearing transcripts, 8 legal memoranda, correspondence, deposition and trial exhibits, expert reports, attorney 9 work product, and consultant and expert work product, even if such materials contain 10 Protected Material. Any such archival copies that contain or constitute Protected 11 Material remain subject to this Protective Order as set forth in Section 4 (DURATION). 12 /// 13 /// 14 15 /// 16 /// 17 /// 18 /// 19 /// 20 /// 21 /// 22 /// 23 /// 24 25 26 27 28 1|{14. VIOLATION 2 || Any violation of this Order may be punished by appropriate measures including, 3 || without limitation, contempt proceedings and/or monetary sanctions. 4 IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD. 5 6 Dated: December 4, 2019 THE LAW OFFICE OF KEVIN S. CONLOGUE 7 8 By: /s/ Keeéa S. 9 KEVIN S. CONLOGUE Attorney for Plaintiffs, PALOMA BELL and 10 MICHAEL COSCHIGANO 11 MICHAEL N. FEUER, City Attorney KATHLEEN A. KENEALY, Chief Asst. City Atty 12 SCOTT MARCUS, Chief, Civil Litigation Branch B CORY M. BRENTE, Senior Asst. City Atty. 14 15 Dated: December 4, 2019 By: ____/s/ Geolleey Dlowdea GEOFFREY PLOWDEN 16 Attorneys tor Defendant CITY OF LOS ANGELES 17 18 || Dated: December 4, 2019 REILY & JEFFERY, INC. 19 20 By: ___/s/ fauine K. Geffery 21 JANINE K. JEFFERY Attorney for Defendant CHRIS JONES 23 FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. DATED: December 6, 2019 25 en Rnb 27 || HON. ALICIA G. ROSENBEXG 28 || United States Magistrate Judge 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 that 6 I have read in its entirety and understand the Stipulated Protective Order that was issued 7 by the United States District Court for the Central District of California on [date] in the 8 case of Dexter White v. City of Los Angeles, et al., 2:19-cv-00243-DDP-RAO. I agree 9 to comply with and to be bound by all the terms of this Stipulated Protective Order and 10 I understand and acknowledge that failure to so comply could expose me to sanctions 11 and 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 Order 13 to any person or entity except in strict compliance with the provisions of this Order. 14 I further agree to submit to the jurisdiction of the United States District Court for the 15 Central District of California for enforcing the terms of this Stipulated Protective Order, 16 even if such enforcement proceedings occur after termination of this action. I hereby 17 appoint __________________________ [print or type full name] of 18 _______________________________________ [print or type full address and 19 telephone number] as my California agent for service of process in connection with this 20 action or any proceedings related to enforcement of this Stipulated Protective Order. 21 Date: ______________________________________ 22 City and State where sworn and signed: _________________________________ 23 24 25 Printed name: _______________________________ 26 Signature: __________________________________ 27 28