SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BLYTHE 265 N. Broadway, Blythe, CA 92225 HEMET 880 N. State St., Hemet, CA 92543 INDIO 46-200 Oasis St., Indio, CA 92201 RIVERSIDE 4175 Main St., Riverside, CA 92501 RI-1A ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): PETITIONER: RESPONDENT: CASE NUMBER: CERTIFICATE OF COUNSEL The undersigned certifies that this matter tried or heard in the Blythe for the following reasons: Hemet Indio Riverside The domestic domicile is located within the geographic boundaries. Other (specify): I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Date: (TYPE OR PRINT NAME OF ATTORNEY OR PARTY MAKING DECLARATION) (SIGNATURE) Adopted for Mandatory Use Riverside Superior court RI-1A [Rev. 12/12/11] CERTIFICATE OF COUNSEL riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com