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UNITED STATES DISTRICT COURT

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CENTRAL DISTRICT OF CALIFORNIA

12 13 BOBBY ACEVES, Case No.: 2:21-cv-04625-PA-RAO

14 Plaintiff, DISCOVERY MATTER

15 vs. Honorable Rozella A. Oliver

16 CITY OF LONG BEACH; OFFICER STIPULATED PROTECTIVE

JOHN ANTHONY MORAN (117457); ORDER

17 and DOES 1 through 10, inclusive,

18 Defendants. Complaint Filed: June 8, 2021 Trial Date: None 19 1. A. PURPOSES AND LIMITATIONS 20 Discovery in this action is likely to involve production of confidential, 21 proprietary or private information for which special protection from public disclosure 22 and from use for any purpose other than prosecuting this litigation may be warranted. 23 Accordingly, the parties hereby stipulate to and petition the Court to enter the 24 following Stipulated Protective Order. The parties acknowledge that this Order does 25 not confer blanket protections on all disclosures or responses to discovery and that 26 the protection it affords from public disclosure and use extends only to the limited 27 1 information or items that are entitled to confidential treatment under the applicable 2 legal principles. 3 B. GOOD CAUSE STATEMENT 4 Though Plaintiff may be entitled, in certain limited circumstances, to examine 5 and receive information in police officers’ personnel files, internal affairs files and 6 force reports, to the extent that they are relevant to their claims in the above-captioned 7 action, the Long Beach Police Department (the “Department”) contends that a 8 protective order is necessary to prevent random distribution of such information. 9 Furthermore, this proposed protective order was created for the purpose of protecting 10 certain information that may be subject to the official information privilege, law 11 enforcement privilege and the right to privacy, as protected by the California and 12 United States Constitution, balanced with plaintiff’s right to discovery in this 13 litigation. 14 The Department and Defendants herein contend that they have an interest in 15 protecting their privacy rights relating to information in his personnel files and other 16 related information. 17 It is the policy of the Department not to disclose information contained in 18 background investigations about its employees, or other information contained in 19 confidential police personnel files unless ordered to do so by a court of competent 20 jurisdiction. Further, it is the policy of the Department not to disclose information 21 contained in police reports to those other than the parties involved in the incident, 22 their representatives, prosecutors, etc. unless ordered to do so by a court of competent 23 jurisdiction. 24 Within the Department, access to personnel files is restricted to those on a 25 “need to know” basis. Controlled access to the files is regarded by the Department as 26 essential in order to assure the integrity and security of such files. The Department 27 contends that uncontrolled disclosure of such information can disrupt the 1 confidential personnel and related files, affect the morale of Department’s personnel, 2 and frustrate the legitimate purposes of gathering the information in these files, 3 including adversely impacting disciplinary procedures within the Department. 4 With respect to police reports, unfettered access is not granted to the public. 5 Instead, access is restricted to those investigating the incident, involved in the incident 6 or their representatives, those who are prosecuting and/or defending those involved, 7 and those who maintain the records. The Department contends that controlled access 8 is necessary to not only assure the integrity and security of said files, but also to ensure 9 the privacy rights of those involved especially third-party witnesses and minors are 10 protected. Permitting uncontrolled disclosure can disrupt the Department’s day-to- 11 day operations, including but not limited to adversely impacting the Department’s 12 ability to thoroughly investigate incidents. 13 Further, the Department contends that information contained in the requested 14 material case files is gathered and maintained in confidence by the Department. The 15 information gathered in these case files generally includes the statements of third- 16 party witnesses collected in confidence. Witnesses are told that the confidentiality of 17 their statement will be protected and that they are for the confidential use of the 18 Department. The Department believes that uncontrolled release of this information 19 would cause needless intrusion into and violation of privacy rights. 20 In light of the nature of the claims and allegations in this case and the parties’ 21 representations that discovery in this case will involve the production of confidential 22 records, and in order to expedite the flow of information, to facilitate the prompt 23 resolution of disputes over confidentiality of discovery materials, to adequately 24 protect information the parties are entitled to keep confidential, to ensure that the 25 parties are permitted reasonable necessary uses of such material in connection with 26 this action, to address their handling of such material at the end of the litigation, and 27 to serve the ends of justice, a protective order for such information is justified in this 1 without a good faith belief that such information/documents have been maintained in 2 a confidential, non-public manner, and that there is good cause or a compelling reason 3 why it should not be part of the public record of this case. 4 C. ACKNOWLEDGMENT OF PROCEDURE FOR FILING UNDER SEAL 5 The parties further acknowledge, as set forth in Section 12.3, below, that this 6 Stipulated Protective Order does not entitle them to file confidential information 7 under seal; Local Civil Rule 79-5 sets forth the procedures that must be followed and 8 the standards that will be applied when a party seeks permission from the court to file 9 material under seal. 10 There is a strong presumption that the public has a right of access to judicial 11 proceedings and records in civil cases. In connection with non-dispositive motions, 12 good cause must be shown to support a filing under seal. See Kamakana v. City and 13 County of Honolulu, 447 F.3d 1172, 1176 (9th Cir. 2006); Phillips v. Gen. Motors 14 Corp., 307 F.3d 1206, 1210-11 (9th Cir. 2002); Makar-Welbon v. Sony Electrics, Inc., 15 187 F.R.D. 576, 577 (E.D. Wis. 1999) (even stipulated protective orders require good 16 cause showing), and a specific showing of good cause or compelling reasons with 17 proper evidentiary support and legal justification, must be made with respect to 18 Protected Material that a party seeks to file under seal. The parties’ mere designation 19 of Disclosure or Discovery Material as CONFIDENTIAL does not—without the 20 submission of competent evidence by declaration, establishing that the material 21 sought to be filed under seal qualifies as confidential, privileged, or otherwise 22 protectable—constitute good cause. 23 Further, if a party requests sealing related to a dispositive motion or trial, then 24 compelling reasons, not only good cause, for the sealing must be shown, and the relief 25 sought shall be narrowly tailored to serve the specific interest to be protected. See 26 Pintos v. Pacific Creditors Ass’n, 605 F.3d 665, 677-79 (9th Cir. 2010). For each 27 item or type of information, document, or thing sought to be filed or introduced under 1 articulate compelling reasons, supported by specific facts and legal justification, for 2 the requested sealing order. Again, competent evidence supporting the application to 3 file documents under seal must be provided by declaration. 4 Any document that is not confidential, privileged, or otherwise protectable in 5 its entirety will not be filed under seal if the confidential portions can be redacted. 6 If documents can be redacted, then a redacted version for public viewing, omitting 7 only the confidential, privileged, or otherwise protectable portions of the document 8 shall be filed. Any application that seeks to file documents under seal in their 9 entirety should include an explanation of why redaction is not feasible. 10 2. DEFINITIONS 11 2.1 Action: 2:21-cv-04625-PA-RAO, Bobby Aceves v. City of Long Beach, 12 et al. 13 2.2 Challenging Party: a Party or Non-Party that challenges the designation 14 of information or items under this Order. 15 2.3 “CONFIDENTIAL” Information or Items: information (regardless of 16 how it is generated, stored or maintained) or tangible things that qualify for protection 17 under Federal Rule of Civil Procedure 26(c), and as specified above in the Good 18 Cause Statement. 19 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as their 20 support staff). 21 2.5 Designating Party: a Party or Non-Party that designates information or 22 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 or 27 generated in disclosures or responses to discovery in this matter. 1 pertinent to the litigation who has been retained by a Party or its counsel to serve as 2 an expert witness or as a consultant in this Action. 3 2.8 House Counsel: attorneys who are employees of a party to this Action. 4 House Counsel does not include Outside Counsel of Record or any other outside 5 counsel. 6 2.9 Non-Party: any natural person, partnership, corporation, association or 7 other legal entity not named as a Party to this action. 8 2.10 Outside Counsel of Record: attorneys who are not employees of a party 9 to this Action but are retained to represent or advise a party to this Action and have 10 appeared in this Action on behalf of that party or are affiliated with a law firm that 11 has appeared on behalf of that party, and includes support staff. 12 2.11 Party: any party to this Action, including all of its officers, directors, 13 employees, consultants, retained experts, and Outside Counsel of Record (and their 14 support staffs). 15 2.12 Producing Party: a Party or Non-Party that produces Disclosure or 16 Discovery Material in this Action. 17 2.13 Professional Vendors: persons or entities that provide litigation support 18 services (e.g., photocopying, videotaping, translating, preparing exhibits or 19 demonstrations, and organizing, storing, or retrieving data in any form or medium) 20 and their employees and subcontractors. 21 2.14 Protected Material: any Disclosure or Discovery Material that is 22 designated as “CONFIDENTIAL.” 23 2.15 Receiving Party: a Party that receives Disclosure or Discovery Material 24 from a Producing Party. 25 3. SCOPE 26 The protections conferred by this Stipulation and Order cover not only 27 Protected Material (as defined above), but also (1) any information copied or extracted 1 Protected Material; and (3) any testimony, conversations, or presentations by Parties 2 or their Counsel that might reveal Protected Material. 3 Any use of Protected Material at trial shall be governed by the orders of the 4 trial judge. This Order does not govern the use of Protected Material at trial. 5 4. DURATION 6 Once a case proceeds to trial, information that was designated as 7 CONFIDENTIAL or maintained pursuant to this protective order used or introduced 8 as an exhibit at trial becomes public and will be presumptively available to all 9 members of the public, including the press, unless compelling reasons supported by 10 specific factual findings to proceed otherwise are made to the trial judge in advance 11 of the trial. See Kamakana, 447 F.3d at 1180-81 (distinguishing “good cause” 12 showing for sealing documents produced in discovery from “compelling reasons” 13 standard when merits-related documents are part of court record). Accordingly, the 14 terms of this protective order do not extend beyond the commencement of the trial. 15 5. DESIGNATING PROTECTED MATERIAL 16 5.1 Exercise of Restraint and Care in Designating Material for Protection. 17 Each Party or Non-Party that designates information or items for protection under this 18 Order must take care to limit any such designation to specific material that qualifies 19 under the appropriate standards. The Designating Party must designate for protection 20 only those parts of material, documents, items or oral or written communications that 21 qualify so that other portions of the material, documents, items or communications 22 for which protection is not warranted are not swept unjustifiably within the ambit of 23 this Order. 24 Mass, indiscriminate or routinized designations are prohibited. Designations 25 that are shown to be clearly unjustified or that have been made for an improper 26 purpose (e.g., to unnecessarily encumber the case development process or to impose 27 unnecessary expenses and burdens on other parties) may expose the Designating Party 1 If it comes to a Designating Party’s attention that information or items that it 2 designated for protection do not qualify for protection, that Designating Party must 3 promptly notify all other Parties that it is withdrawing the inapplicable designation. 4 5.2 Manner and Timing of Designations. Except as otherwise provided in 5 this Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise 6 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection 7 under this Order must be clearly so designated before the material is disclosed or 8 produced. 9 Designation in conformity with this Order requires: 10 (a) for information in documentary form (e.g., paper or electronic 11 documents, but excluding transcripts of depositions or other pretrial or trial 12 proceedings), that the Producing Party affix at a minimum, the legend 13 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 14 contains protected material. If only a portion of the material on a page qualifies for 15 protection, the Producing Party also must clearly identify the protected portion(s) 16 (e.g., by making appropriate markings in the margins). 17 A Party or Non-Party that makes original documents available for inspection 18 need not designate them for protection until after the inspecting Party has indicated 19 which documents it would like copied and produced. During the inspection and 20 before the designation, all of the material made available for inspection shall be 21 deemed “CONFIDENTIAL.” After the inspecting Party has identified the documents 22 it wants copied and produced, the Producing Party must determine which documents, 23 or portions thereof, qualify for protection under this Order. Then, before producing 24 the specified documents, the Producing Party must affix the “CONFIDENTIAL 25 legend” to each page that contains Protected Material. If only a portion of the material 26 on a page qualifies for protection, the Producing Party also must clearly identify the 27 protected portion(s) (e.g., by making appropriate markings in the margins). 1 the Disclosure or Discovery Material on the record, before the close of the deposition 2 all protected testimony. 3 (c) for information produced in some form other than documentary and for 4 any other tangible items, that the Producing Party affix in a prominent place on the 5 exterior of the container or containers in which the information is stored the legend 6 “CONFIDENTIAL.” If only a portion or portions of the information warrants 7 protection, the Producing Party, to the extent practicable, shall identify the protected 8 portion(s). 9 5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent 10 failure to designate qualified information or items does not, standing alone, waive the 11 Designating Party’s right to secure protection under this Order for such material. 12 Upon timely correction of a designation, the Receiving Party must make reasonable 13 efforts to assure that the material is treated in accordance with the provisions of this 14 Order. 15 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 16 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 17 designation of confidentiality at any time that is consistent with the Court’s 18 Scheduling Order. 19 6.2 Meet and Confer. The Challenging Party shall initiate the dispute 20 resolution process under Local Rule 37.1 et seq. 21 6.3 The burden of persuasion in any such challenge proceeding shall be on 22 the Designating Party. Frivolous challenges, and those made for an improper purpose 23 (e.g., to harass or impose unnecessary expenses and burdens on other parties) may 24 expose the Challenging Party to sanctions. Unless the Designating Party has waived 25 or withdrawn the confidentiality designation, all parties shall continue to afford the 26 material in question the level of protection to which it is entitled under the Producing 27 Party’s designation until the Court rules on the challenge. 1 7. ACCESS TO AND USE OF PROTECTED MATERIAL 2 7.1 Basic Principles. A Receiving Party may use Protected Material that is 3 disclosed or produced by another Party or by a Non-Party in connection with this 4 Action only for prosecuting, defending or attempting to settle this Action. Such 5 Protected Material may be disclosed only to the categories of persons and under the 6 conditions described in this Order. When the Action has been terminated, a Receiving 7 Party must comply with the provisions of section 13 below (FINAL DISPOSITION). 8 Protected Material must be stored and maintained by a Receiving Party at a 9 location and in a secure manner that ensures that access is limited to the persons 10 authorized under this Order. 11 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 12 otherwise ordered by the court or permitted in writing by the Designating Party, a 13 Receiving Party may disclose any information or item designated 14 “CONFIDENTIAL” only to: 15 (a) the Receiving Party’s Outside Counsel of Record in this Action, as well 16 as employees of said Outside Counsel of Record to whom it is reasonably necessary 17 to disclose the information for this Action; 18 (b) the officers, directors, and employees (including House Counsel) of the 19 Receiving Party to whom disclosure is reasonably necessary for this Action; 20 (c) Experts (as defined in this Order) of the Receiving Party to whom 21 disclosure is reasonably necessary for this Action and who have signed the 22 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 23 (d) the court and its personnel; 24 (e) court reporters and their staff; 25 (f) professional jury or trial consultants, mock jurors, and Professional 26 Vendors to whom disclosure is reasonably necessary for this Action and who have 27 signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A); 1 custodian or other person who otherwise possessed or knew the information; 2 (h) during their depositions, witnesses, and attorneys for witnesses, in the 3 Action to whom disclosure is reasonably necessary provided: (1) the deposing party 4 requests that the witness sign the form attached as Exhibit A hereto; and (2) they will 5 not be permitted to keep any confidential information unless they sign the 6 “Acknowledgment and Agreement to Be Bound” (Exhibit A), unless otherwise 7 agreed by the Designating Party or ordered by the court. Pages of transcribed 8 deposition testimony or exhibits to depositions that reveal Protected Material may be 9 separately bound by the court reporter and may not be disclosed to anyone except as 10 permitted under this Stipulated Protective Order; and 11 (i) any mediator or settlement officer, and their supporting personnel, 12 mutually agreed upon by any of the parties engaged in settlement discussions. 13 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED 14 IN OTHER LITIGATION 15 If a Party is served with a subpoena or a court order issued in other litigation 16 that compels disclosure of any information or items designated in this Action as 17 “CONFIDENTIAL,” that Party must: 18 (a) promptly notify in writing the Designating Party. Such notification shall 19 include a copy of the subpoena or court order; 20 (b) promptly notify in writing the party who caused the subpoena or order 21 to issue in the other litigation that some or all of the material covered by the subpoena 22 or order is subject to this Protective Order. Such notification shall include a copy of 23 this Stipulated Protective Order; and 24 (c) cooperate with respect to all reasonable procedures sought to be pursued 25 by the Designating Party whose Protected Material may be affected. 26 If the Designating Party timely seeks a protective order, the Party served with 27 the subpoena or court order shall not produce any information designated in this action 1 or order issued, unless the Party has obtained the Designating Party’s permission. The 2 Designating Party shall bear the burden and expense of seeking protection in that court 3 of its confidential material and nothing in these provisions should be construed as 4 authorizing or encouraging a Receiving Party in this Action to disobey a lawful 5 directive from another court. 6 9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE 7 PRODUCED IN THIS LITIGATION 8 (a) The terms of this Order are applicable to information produced by a 9 Non-Party in this Action and designated as “CONFIDENTIAL.” Such information 10 produced by Non-Parties in connection with this litigation is protected by the 11 remedies and relief provided by this Order. Nothing in these provisions should be 12 construed as prohibiting a Non-Party from seeking additional protections. 13 (b) In the event that a Party is required, by a valid discovery request, to 14 produce a Non-Party’s confidential information in its possession, and the Party is 15 subject to an agreement with the Non-Party not to produce the Non-Party’s 16 confidential information, then the Party shall: 17 (1) promptly notify in writing the Requesting Party and the Non-Party 18 that some or all of the information requested is subject to a confidentiality agreement 19 with a Non-Party; 20 (2) promptly provide the Non-Party with a copy of the Stipulated 21 Protective Order in this Action, the relevant discovery request(s), and a reasonably 22 specific description of the information requested; and 23 (3) make the information requested available for inspection by the Non- 24 Party, if requested. 25 (c) If the Non-Party fails to seek a protective order from this court within 26 14 days of receiving the notice and accompanying information, the Receiving Party 27 may produce the Non-Party’s confidential information responsive to the discovery 1 not produce any information in its possession or control that is subject to the 2 confidentiality agreement with the Non-Party before a determination by the court. 3 Absent a court order to the contrary, the Non-Party shall bear the burden and expense 4 of seeking protection in this court of its Protected Material. 5 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL 6 If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 7 Protected Material to any person or in any circumstance not authorized under this 8 Stipulated Protective Order, the Receiving Party must immediately (a) notify in 9 writing the Designating Party of the unauthorized disclosures, (b) use its best efforts 10 to retrieve all unauthorized copies of the Protected Material, (c) inform the person or 11 persons to whom unauthorized disclosures were made of all the terms of this Order, 12 and (d) request such person or persons to execute the “Acknowledgment and 13 Agreement to Be Bound” that is attached hereto as Exhibit A. 14 11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 15 PROTECTED MATERIAL 16 When a Producing Party gives notice to Receiving Parties that certain 17 inadvertently produced material is subject to a claim of privilege or other protection, 18 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 19 Procedure 26(b)(5)(B). This provision is not intended to modify whatever procedure 20 may be established in an e-discovery order that provides for production without prior 21 privilege review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the 22 parties reach an agreement on the effect of disclosure of a communication or 23 information covered by the attorney-client privilege or work product protection, the 24 parties may incorporate their agreement in the stipulated protective order submitted 25 to the court. 26 12. MISCELLANEOUS 27 12.1 Right to Further Relief. Nothing in this Order abridges the right of any 1 12.2 Right to Assert Other Objections. By stipulating to the entry of this 2 Protective Order, no Party waives any right it otherwise would have to object to 3 disclosing or producing any information or item on any ground not addressed in this 4 Stipulated Protective Order. Similarly, no Party waives any right to object on any 5 ground to use in evidence of any of the material covered by this Protective Order. 6 12.3 Filing Protected Material. A Party that seeks to file under seal any 7 Protected Material must comply with Local Civil Rule 79-5. Protected Material may 8 only be filed under seal pursuant to a court order authorizing the sealing of the specific 9 Protected Material at issue. If a Party’s request to file Protected Material under seal 10 is denied by the court, then the Receiving Party may file the information in the public 11 record unless otherwise instructed by the court. 12 13. FINAL DISPOSITION 13 After the final disposition of this Action, as defined in paragraph 4, within 60 14 days of a written request by the Designating Party, each Receiving Party must return 15 all Protected Material to the Producing Party or destroy such material. As used in this 16 subdivision, “all Protected Material” includes all copies, abstracts, compilations, 17 summaries, and any other format reproducing or capturing any of the Protected 18 Material. Whether the Protected Material is returned or destroyed, the Receiving 19 Party must submit a written certification to the Producing Party (and, if not the same 20 person or entity, to the Designating Party) by the 60 day deadline that (1) identifies 21 (by category, where appropriate) all the Protected Material that was returned or 22 destroyed and (2) affirms that the Receiving Party has not retained any copies, 23 abstracts, compilations, summaries or any other format reproducing or capturing any 24 of the Protected Material. Notwithstanding this provision, Counsel are entitled to 25 retain an archival copy of all pleadings, motion papers, trial, deposition, and hearing 26 transcripts, legal memoranda, correspondence, deposition and trial exhibits, expert 27 reports, attorney work product, and consultant and expert work product, even if such 1 || constitute Protected Material remain subject to this Protective Order as set forth in 2 || Section 4 (DURATION). 3 || 14. VIOLATION 4 Any violation of this Order may be punished by appropriate measures 5 || including, without limitation, contempt proceedings and/or monetary sanctions. 6 7 || ITIS SO STIPULATED, THROUGH COUNSEL OF RECORD. 8 9 || DATED: September 3, 2021 10 || /s/ Peter Carr, Esq. 11 || Attorneys forPlaintiff! = 12 13 4 DATED: September 3, 2021

/s/ Matthew M. Peters! 16 Attorneys for Defendant 17 18 || FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. 19 0 || DATED: September 8, 2021 21 | Rayethn a. QA 93 || HON. ROZELLA A. OLIVER United States Magistrate Judge 24 25 26 27 | I, Matthew Peters, Attorney for Defendants, attest that all other signatories listed, 3g || and on whose behalf the filing is submitted, concur in the filing’s content and have authorized this filing.

1 EXHIBIT A 2 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND 3 I, _____________________________ [print or type full name], of 4 _________________ [print or type full address], declare under penalty of perjury that 5 I have read in its entirety and understand the Stipulated Protective Order that was 6 issued by the United States District Court for the Central District of California on 7 [date] in the case of ___________ [insert formal name of the case and the number 8 and initials assigned to it by the court]. I agree to comply with and to be bound by 9 all the terms of this Stipulated Protective Order and I understand and acknowledge 10 that failure to so comply could expose me to sanctions and punishment in the nature 11 of contempt. I solemnly promise that I will not disclose in any manner any 12 information or item that is subject to this Stipulated Protective Order to any person or 13 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 15 for the Central District of California for enforcing the terms of this Stipulated 16 Protective Order, even if such enforcement proceedings occur after termination of this 17 action. I hereby 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 20 this action or any proceedings related to enforcement of this Stipulated Protective 21 Order. 22 Date: ______________________________________ 23 City and State where sworn and signed: _________________________________ 24 25 Printed name: _______________________________ 26 27 Signature: __________________________________