NAME AND ADDRESS OF PARTY OR ATTORNEY FOR PARTY: TELEPHONE NUMBER: FOR COURT USE ONLY ATTORNEY FOR(NAME): SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 Main Street El Centro, CA 92243 PETITIONER: RESPONDENT: APPLICATION REGARDING EX PARTE REQUEST CASE NUMBER: REASONS FOR EX PARTE RELIEF You must specify why this request cannot be heard on the court’s regular motion calendar. Only include factual information within your personal knowledge, and not conclusions, feelings or fears. (IF CUSTODY OR VISITION IS AT ISSUE, YOU MUST CLEARLY SHOW WHY THERE IS A RISK OF IMMEDIATE HARM TO YOUR CHILD OR CHILDREN, OR WHY THERE IS AN IMMEDIATE RISK THAT YOUR CHILD WILL BE REMOVED FROM CALIFORNIA.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct, and that this declaration was signed at_____________, California. Date: ___________________ Signature: _________________________________ Print Name: _________________________________ Please submit your proposed order as an attachment to this declaration in clear handwritten or typewritten form. INTERPRETER’S DECLARATION I certify under penalty of perjury under the laws of the State of California that I have, to the best of my ability, read or translated for the declarant above this Declaration for Ex Parte Hearing. The declarant above has expressly indicated that he or she understood this document before signing it. Date: ___________________ Signature: _________________________________ Print Name:________________________________ Form Approved for Optional Use FL-06 (B) (01/01/10; Revised 01/01/11) American LegalNet, Inc. www.FormsWorkFlow.com