ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, address and telephone #): FOR COURT USE ONLY STATE BAR NO: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF MARIN 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 CONTESTANT: NAME: ADDRESS: LOCAL AGENCY: CASE NUMBER: NOTICE OF ADMINISTRATIVE APPEAL - GENERAL Government Code § 53069.4(b)(1) As the contestant in the above entitled action, I hereby appeal the final administrative order/decision of the _______________________________ Officer issued on: ________________________. The mailing date of the final administrative order/decision by the ________________________________________ was: _________________________. MANDATORY REQUIREMENTS • This Notice of Appeal must be filed with the Court within 20 days after service of the final administrative order/decision by the ___________________________________; • A filing fee of $25.00 is required at the time of filing; • No later than 15 days subsequent to filing Notice of Appeal, you must file proof of service with this Court that the local agency was served with this Notice of Appeal either in person or by first-class mail; and • Failure to comply with each of these requirements may result in the dismissal of your appeal or denial of a de novo hearing. I declare under penalty of perjury that the foregoing is true and correct. Date: _______________________________ SIGNATURE OF CONTESTANT A hearing will be conducted at the Marin County Superior Court, Hall of Justice, San Rafael, California, on the date and time indicated below: DATE TIME AM / PM KIM TURNER Court Executive Officer Date: _______________________________ By: DEPUTY Upon receipt of this Notice of Administrative Appeal, the local agency shall be responsible for sending the complete file to The Marin County Superior Court within 15 days. CV027WB NOTICE OF ADMINISTRATIVE APPEAL - GENERAL Rev. 7/07 American LegalNet, Inc. www.FormsWorkflow.com