COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. DECLARATION FOR THE RECEIPT OF : CONFIDENTIAL JUVENILE JUDICIAL SUBPOENA INFORMATION Plaintiff(s) -against: I, __________________________________, request that information concerning a traffic accident or crime incident contained in Nevada County Sheriff's : Department Grass Valley Police Department Nevada County Police Department California Department of Parks & Recreation: Other _____________________ Case No. ___________________ be released to me. I acknowledge that the information Defendant(s) being released to me is CONFIDENTIAL, in that it contains information concerning one or : ...................................................... more juveniles. I acknowledge that: (1) the information is being released to me pursuant to a Nevada THE STATE OF NEW YORK THE PEOPLE OF County Juvenile Court Standing Order; and (2) my use of this information and the persons to whom I may disclose this information is restricted by that Order; and (3) that TO ANY VIOLATION OF AN ORDER OF A SUPERIOR COURT JUDGE, WHICH MAY SUBJECT ME TO PROSECUTION FOR CONTEMPT OF COURT under California Penal Code Section 166. Section IIIG of the Standing Order provides in pertinent part as follows: "G. . . . The information is to be released only for purposes of assessing the person or entity in obtaining the reimbursement for injuries or damages WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before caused by the conduct of the minor(s). TheCourt person to whom the information , the Honorable at the is released shall agree in writing that the person other than their attorney, located at County of insurance adjuster or other person legally representing the person's or entity's in room , on the day of , 20 , at o'clock in the noon, and at any recessed interest and give evidence as a witness in this action on the incident. or adjourned date, to testifyin recovering damages resulting from the part of the The person to whom the information is released shall also agree in writing that the information is released shall also agree in writing that the information will be used by them for no purpose other than as stated above . . ." GREETINGS: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a By my signature hereon, I acknowledge that I have read the above and understand result of your failure to comply. its contents and agree not to make any use of disclosure of any of the information provided to me other than as allowed by the Juvenile Court as stated herein. Witness, Honorable , one of the Justices of the County, day of , 20 that I, or a person or entity I am authorized to I declare under penalty of perjury Court in represent, was damaged by or a victim of the conduct of minor(s) who is the subject of the above listed law enforcement report. I (or the person or entity I represent) further declare (Attorney must sign above and of name minor(s) and will that I have suffered injury or damages as a result of the conduct type saidbelow) use the information provided me only for the purpose of obtaining reimbursement for the injury or damage suffered by me. Attorney(s) for Executed on ______________________________, at Nevada City, California. ______________________________ DECLARANT Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: ________________________________________________________________________________________________________________________________________________ DECLARATION FOR THE RECEIPT OF CONFIDENTIAL JUVENILE INFORMATION LOCAL JV5(Effective 7/1/03) American LegalNet, Inc. www.USCourtForms.com