ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, address and telephone #): FOR COURT USE ONLY STATE BAR NO: ATTORNEY FOR (Name): MARIN COUNTY SUPERIOR COURT 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 APPELLANT: NAME: ADDRESS: NOTICE OF ADMINISTRATIVE APPEAL - GENERAL Government Code § 53069.4(b)(1) CASE NUMBER: As the appellant, I hereby appeal the final administrative order/decision of an official at (local agency) ___________________________________________ issued on: ____________________. The mailing date of the final administrative order/decision was: . MANDATORY REQUIREMENTS This Notice of Appeal must be filed with the court within 20 days after service of the final administrative order/decision; A filing fee of $25.00 is required at the time of filing; No later than 15 days subsequent to filing Notice of Appeal, you must file proof of service with this court that the local agency was served with this Notice of Appeal either in person or by first-class mail; and Failure to comply with each of these requirements may result in the dismissal of your appeal or denial of a de novo hearing. I declare under penalty of perjury that the foregoing is true and correct. DATE APPELLANT'S SIGNATURE A hearing will be conducted at the Marin County Superior Court on _________________________________ at ______________________ AM / PM in courtroom _________. KIM TURNER Court Executive Officer Date: By: DEPUTY Upon receipt of this notice, the local agency shall be responsible for sending the complete file to the Marin County Superior Court within 15 days. CV027 NOTICE OF ADMINISTRATIVE APPEAL - GENERAL Rev. 5/29/15 American LegalNet, Inc. www.FormsWorkFlow.com