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: PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: PEREMPTORY CHALLENGE TO JUDICIAL OFFICER CASE NUMBER: (Code Civ. Proc., § 170.6) Name of Judicial Officer: (PRINT) Dept. Number: Judge Commissioner Referee I am a party (or attorney for a party) to this action or special proceeding. The judicial officer named above, before whom the trial of, or a hearing in, this case is pending, or to whom it has been assigned, is prejudiced against the party (or his or her attorney) or the interest of the party (or his or her attorney), so that declarant cannot, or believes that he or she cannot, have a fair and impartial trial or hearing before the judicial officer. DECLARATION I declare under penalty of perjury, under the laws of the State of California, that the information entered on this form is true and correct. Filed on behalf of: Name of Party Plaintiff/Petitioner Defendant/Respondent Other: Cross Complainant Cross Defendant Dated: Signature of Declarant Printed Name LACIV 015 (Rev. 12-14) LASC Approved 04-04 For Optional Use PEREMPTORY CHALLENGE TO JUDICIAL OFFICER (Code Civ. Proc., § 170.6) Code Civ. Proc., § 170.6 American LegalNet, Inc. www.FormsWorkFlow.com