MJV-102 Application submitted by: (Name and Address) Name: Street Address: City, State, Zip Code: Telephone No. FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF MENDOCINO Street Address: City and Zip Code: Branch Name: Child's Name: 100 North State Street Ukiah, CA 95482 SITTING AS THE JUVENILE COURT DECLARATION: INFORMAL EXCHANGE OF JUVENILE RECORDS (Welf. & Inst. §827, Rule of Court 5.552) I, 1. CASE NUMBER: , do hereby declare: That I am a person described in Mendocino County Local rule of Court 16.10(c), specifically, 2. That I am requesting to view and copy juvenile records, as described on the attached page, concerning the above-named child/minor currently in the possession of the: Juvenile Court Probation Dept. Dept. of Social Services Court-Appointed Special Advocate Family Court Services 3. That I certify that I am requesting these records for use in my official capacity and that I will not disseminate any portion of the records released to me or information relating to their contents, other than to other persons or agencies described in S.O. 99-021 and that no portion of those records and no information relating to the contents of those records shall be made attachments to any other documents without the prior approval of the presiding Judge of the Juvenile Court, unless they are used in connection with and in the course of a criminal investigation or a proceeding brought to declare a person a dependent child or ward of the juvenile court. I declare under penalty of perjury that the above is true and correct. Executed this Day of in Ukiah, California. Signature: MJV-102 (rev 010117) American LegalNet, Inc. www.FormsWorkFlow.com