ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): Bar No: SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE JUSTICE CENTER: Central - 700 Civic Center Dr. West, Santa Ana, CA 92701-4045 Harbor ­ Newport Beach Facility, 4601 Jamboree Rd., Newport Beach, CA 92660 Lamoreaux - 341 The City Drive South, Orange, CA 92868-3205 North ­ 1275 N. Berkeley Ave., P.O. Box 5000, Fullerton, CA 92838 West ­ 8141 13th Street, Westminster, CA 92683 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: CASE NUMBER: JUDICIAL OFFICER: DECLARATION IN SUPPORT OF MOTION RE DISQUALIFICATION OF JUDICIAL OFFICER PURSUANT TO C.C.P. 170.6 I am a party DEPARTMENT: the attorney for a party in the above entitled case and declare that ___________________________________________________, the judicial officer before whom the trial or hearing in this action or special proceeding is pending, or to whom this case is assigned, is prejudiced against the party or the party's attorney, or the interest of the party or party's attorney, such that the declarant cannot, or believes that he/she cannot, have a fair and impartial trial or hearing before the judicial officer. This judicial officer has has not presided over a hearing, motion, or other proceeding in the past in this case. Pursuant to the provisions of Code of Civil Procedure section 170.6, I request that this case be assigned to another judicial officer for further proceedings. 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) _______________________________________ (Signature of declarant) __________________________________________________________________________________________________________________ Form L-0292 Optional Form Revised February 4, 2014 DECLARATION IN SUPPORT OF MOTION RE DISQUALIFICATION OF JUDICIAL OFFICER PURSUANT TO C.C.P. 170.6 American LegalNet, Inc. www.FormsWorkFlow.com