NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk's File Stamp ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: CONTESTANT: ADDRESS: TELEPHONE NUMBER: PROCESSING AGENCY: ADDRESS: TELEPHONE NUMBER: NOTICE OF APPEAL - ADMINISTRATIVE HEARING NOTICE TO CONTESTANT CASE NUMBER: The contestant is responsible for the timely filing of the Notice of Appeal. A separate Notice of Appeal - Administrative Hearing is required for each citation. When the Court returns a copy of this notice to you with the date, place and time of the hearing filled in, you must serve a copy of this notice upon the processing agency and file a copy of the original Proof of Service of this notice with the Court at least 10 days prior to the hearing date. The Court may not proceed on your appeal if proof of service has not been filed. The Contestant in the above-titled action hereby appeals to the Superior Court of California, County of Los Angeles, from the final administrative decision on citation number: _____________________, which was issued on ______________. (DATE) The hearing was by personal conference. by mailed declaration. The date of the final administrative decision was _____________________. (a copy of the final decision must be attached) The final administrative decision was personally delivered on ______________________. (DATE) mailed on ______________________. (DATE) Dated: _________________________ __________________________________________________________ Signature of Contestant NOTICE OF HEARING For Court Use Only: A hearing will be held in the Superior Court of California, County of Los Angeles, on the date and time shown below. Date Time Dept. Court Location SHERRI R. CARTER, Executive Officer/Clerk Dated: _________________________ By: __________________________________________ Deputy Clerk Gov. Code, § 53069.4 American LegalNet, Inc. www.FormsWorkFlow.com LACIV 232 (NEW) LASC Approved: 06-12 For Optional Use NOTICE OF APPEAL ­ ADMINISTRATIVE HEARING