LSC Form 6A Page 1 of 2 Mandatory Form, as amended 1/1/2012 FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number and address) TELEPHONE NUMBER: ATTORNEY FOR (Name): LASSEN COUNTY SUPERIOR COURT 2610 RIVERSIDE DRIVE, SUSANVILLE, CA 96130 FAX NO: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: REQUEST FOR COURTCALL TELEPHONIC APPEARANCE DATE: JUDGE: TIME: NATURE OF HEARING: DEPT. : 1. _____________________________________ (name of specific attorney appearing telephonically) requests a CourtCall telephonic appearance at the above referenced proceeding and agrees to provisions of the Rule/Order/Procedure RE: CourtCall Telephonic Appearances. Not less than five court days prior to hearing, a copy of this document was served on all other parties and faxed to the CourtCall, LLC, Telephonic Appearance Program Administrator. The non-refundable CourtCall Appearance Fee in the sum of $78 (plus additional fee of $30 if late filing is accepted) is paid as follows: Check (copy attached) payable to Telephonic Hearing Account and original mailed to CourtCall, LLC at 11268 W. Washington Blvd., Suite 200, Culver City, CA 90230; telephone (310) 5724670 or (888) 88COURT. Charge to CourtCall Debit Account No: _____________________________________________. Charged to VISA, MasterCard or American Express: 2. 3. TO BE COMPLETED ONLY ON THE COPY SUBMITTED TO CourtCall, LLC: Credit Card: VISA MasterCard American Express Credit Card Number __________________________________________ Expiration Date: _________________ To pay by credit card, the copy of this form submitted to CourtCall, LLC, must be signed by the person whose card is to be charged and must be faxed to CourtCall, LLC, at (310) American LegalNet, Inc. www.FormsWorkFlow.com 572-4679 of (888) 88FAXIN with the above credit card information completed. The signatures below constitutes authorization to charge the above referenced credit card. The receipt faxed back by CourtCall, LLC, constitutes calendar confirmation. Date: ______________ Name on Card: ____________________________________________ Signature: ______________________________ Please Print Dated: ____________________________ ___________________________________________________ Signature REQUEST FOR COURTCALL TELEPHONIC APPEARANCE American LegalNet, Inc. www.FormsWorkFlow.com