TO BE FILED IN THE COURT OF APPEAL COURT OF APPEAL CASE NUMBER: APP-008 COURT OF APPEAL ATTORNEY OR PARTY WITHOUT ATTORNEY: NAME: FIRM NAME: STREET ADDRESS: CITY: TELEPHONE NO.: E-MAIL ADDRESS: ATTORNEY FOR (name): APPELLATE DISTRICT, DIVISION STATE BAR NO.: SUPERIOR COURT CASE NUMBER: STATE: FAX NO.: ZIP CODE: APPELLANT/ PETITIONER: RESPONDENT/ REAL PARTY IN INTEREST: CERTIFICATE OF INTERESTED ENTITIES OR PERSONS (Check one): INITIAL CERTIFICATE SUPPLEMENTAL CERTIFICATE Notice: Please read rules 8.208 and 8.488 before completing this form. You may use this form for the initial certificate in an appeal when you file your brief or a prebriefing motion, application, or opposition to such a motion or application in the Court of Appeal, and when you file a petition for an extraordinary writ. You may also use this form as a supplemental certificate when you learn of changed or additional information that must be disclosed. 1. This form is being submitted on behalf of the following party (name ): 2. a. b. There are no interested entities or persons that must be listed in this certificate under rule 8.208. Interested entities or persons required to be listed under rule 8.208 are as follows: Full name of interested entity or person (1) (2) (3) (4) (5) Continued on attachment 2. Nature of interest (Explain): The undersigned certifies that the above-listed persons or entities (corporations, partnerships, firms, or any other association, but not including government entities or their agencies) have either (1) an ownership interest of 10 percent or more in the party if it is an entity; or (2) a financial or other interest in the outcome of the proceeding that the justices should consider in determining whether to disqualify themselves, as defined in rule 8.208(e)(2). Date: (TYPE OR PRINT NAME) (SIGNATURE OF APPELLANT OR ATTORNEY) Page 1 of 1 Form Approved for Optional Use Judicial Council of California APP-008 [Rev. January 1, 2017] CERTIFICATE OF INTERESTED ENTITIES OR PERSONS Cal. Rules of Court, rules 8.208, 8.488 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com