CIV-110 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): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: REQUEST FOR DISMISSAL CASE NUMBER: A conformed copy will not be returned by the clerk unless a method of return is provided with the document. This form may not be used for dismissal of a derivative action or a class action or of any party or cause of action in a class action. (Cal. Rules of Court, rules 3.760 and 3.770.) 1. TO THE CLERK: Please dismiss this action as follows: a. (1) b. (1) (3) (4) (5) (6) With prejudice (2) Without prejudice Complaint (2) Petition Cross-complaint filed by (name): Cross-complaint filed by (name): Entire action of all parties and all causes of action Other (specify):* on (date): on (date): 2. (Complete in all cases except family law cases.) The court did did not waive court fees and costs for a party in this case. (This information may be obtained from the clerk. If court fees and costs were waived, the declaration on the back of this form must be completed). Date: .......................................... (TYPE OR PRINT NAME OF ATTORNEY PARTY WITHOUT ATTORNEY) (SIGNATURE) *If dismissal requested is of specified parties only of specified causes of action only, or of specified cross-complaints only, so state and identify the parties, causes of action, or cross-complaints to be dismissed. Attorney or party without attorney for: Plaintiff/Petitioner Defendant/Respondent Cross Complainant 3. TO THE CLERK: Consent to the above dismissal is hereby given.** Date: (TYPE OR PRINT NAME OF ATTORNEY PARTY WITHOUT ATTORNEY) (SIGNATURE) ** If a cross-complaint ­ or Response (Family Law) seeking affirmative relief ­ is on file, the attorney for cross-complainant (respondent) must sign this consent if required by Code of Civil Procedure section 581 (i) or (j). Attorney or party without attorney for: Plaintiff/Petitioner Cross Complainant Defendant/Respondent (To be completed by clerk) Dismissal entered as requested on (date): 4. 5 6. Dismissal entered on (date): as to only (name): Dismissal not entered as requested for the following reasons (specify): 7. a. b. Attorney or party without attorney notified on (date): Attorney or party without attorney not notified. Filing party failed to provide a copy to be conformed means to return conformed copy Clerk, by , Deputy Page 1 of 2 Code of Civil Procedure, § 581 et seq.; Gov. Code, § 68637(c); Cal. Rules of Court, rule 3.1390 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com Date: Form Adopted for Mandatory Use Judicial Council of California CIV-110 [Rev. Jan. 1, 2013] REQUEST FOR DISMISSAL CIV-110 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: CASE NUMBER: COURT'S RECOVERY OF WAIVED COURT FEES AND COSTS If a party whose court fees and costs were initially waived has recovered or will recover $10,000 or more in value by way of settlement, compromise, arbitration award, mediation settlement, or other means, the court has a statutory lien on that recovery. The court may refuse to dismiss the case until the lien is satisfied. (Gov. Code, § 68637.) Declaration Concerning Waived Court Fees 1. The court waived court fees and costs in this action for (name): 2. The person named in item 1 is (check one below): a. not recovering anything of value by this action. b. recovering less than $10,000 in value by this action. c. recovering $10,000 or more in value by this action. (If item 2c is checked, item 3 must be completed.) 3. All court fees and court costs that were waived in this action have been paid to the court (check one): Yes No 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 PARTY MAKING DECLARATION) (SIGNATURE) CIV-110 [Rev. January 1, 2013] REQUEST FOR DISMISSAL Page 2 of 2