COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. TR-160 FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number and address): : Plaintiff(s) TELEPHONE NO.: -against- NO.: FAX Calendar No. : JUDICIAL SUBPOENA : ATTORNEY FOR (Name): : NAME OF COURT: STREET ADDRESS: : MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: Defendant(s) : . . . . . . . . . . . . . . .PEOPLE. OF .THE STATE. OF.CALIFORNIA . . . . . . . ...... .. ........ .. .......... vs. DEFENDANT/APPELLANT (Name): THE PEOPLE OF THE STATE OF NEW YORK CASE NUMBER: PROPOSED STATEMENT ON APPEAL (Infraction) TO Defendant/Appellant (name): submits the following Proposed Statement on Appeal: GROUNDS FOR APPEAL 1. (Specify in detail your reasons for why you feel the judge committed ''error" regarding the law or procedure. Note that credibility of GREETINGS: witnesses is generally not a basis for appeal): WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of b. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the a. c. d. e. 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 result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 f. (Attorney must sign above and type name below) STATEMENT OF EVIDENCE 2. The above-entitled matter was reported by an official court reporter or electronically recorded and appellant intends to file a reporter's transcript of the evidence and proceedings so reported and to make the transcript appellant's statement on appeal. Attorney(s) for 3. Instead of a transcript the appellant is submitting the following statement on appeal: testified that (set forth accurately and in detail the testimony of the officer; a. Officer (name): do not comment on or give your opinion regarding the officer's testimony): Office and P.O. Address Form Approved for Optional Use Judicial Council of California TR-160 [Rev. January 1, 2007] Telephone No.: Facsimile No.: E-Mail Address: PROPOSED STATEMENT ON APPEALTel. No.: Mobile (Infraction) Page 1 of 4 Cal. Rules of Court, rule 8.784 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com TR-160 CASE NUMBER: PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT APPELLANT (Name): 3. (Continued) b. Defendant testified that (set forth defendant's testimony accurately and in detail): c. Witness (name): detail): was called and testified that (set forth witness's testimony accurately and in (Continued on page three) TR-160 [Rev. January 1, 2007] PROPOSED STATEMENT ON APPEAL (Infraction) Page 2 of 4 TR-160 PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT/APPELLANT (Name): CASE NUMBER: 3. c. (Witness testimony continued) Please attach separate page(s) labeled ''Attachment 3d,'' ''Attachment 3e," etc. for each other witness. FINDINGS OF THE COURT 4. The court determined I was guilty and assessed a fine of: $ 5. Number of pages attached: Date: ................................................. (TYPE OR PRINT NAME) (SIGNATURE OF DEFENDANT/APPELLANT OR ATTORNEY) (Proof of service on reverse) TR-160 [Rev. January 1, 2007] PROPOSED STATEMENT ON APPEAL (Infraction) Page 3 of 4 TR-160 PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT/APPELLANT (Name): DIRECTIONS: CASE NUMBER: A copy of this document must be mailed to the district attorney/city attorney at the address listed below. YOU MAY NOT PERFORM THE MAILING YOURSELF. You must have a party who is at least 18 years old complete the information below and mail the front and back of each page of this document by first class mail, postage prepaid. When the fronts and backs of this document have been completed and mailed, the original may then be filed with the court. PROOF OF SERVICE BY MAIL 1. I am over the age of 18 and NOT a party to this action. I am a resident of or employed in the county where the mailing took place. 2. My residence or business address is (specify): 3. I served a copy of the Proposed Statement on Appeal by enclosing it in an envelope AND a. depositing the sealed envelope with the United States Postal Service with the postage fully prepaid. b. placing the envelope for collection and mailing on the date and at the place shown in item 4 following our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service in a sealed envelope with postage fully prepaid. 4. The envelope was addressed and mailed as follows: a. (Name of county): District Attorney/City Attorney b. Address: c. Date mailed: d. Place of mailing (city and state): 5. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) TR-160 [Rev. January 1, 2007] (SIGNATURE OF DECLARANT) PROPOSED STATEMENT ON APPEAL (Infraction) Page 4 of 4