ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NO.: NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: E - MAIL ADDRESS: ATTORNEY FOR (name): 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 92660-2595 North - 1275 N. Berkeley Ave., P. O. Box 5000, Fullerton, CA 92838-0500 West - 8141 13 th Street, Westminster, CA 9 2683 - 4593 PETITIONER: RESPONDENT: DECLARATION OF DEFAULT/NON-COMPLIANCE Civil Harassment Workplace Violence Elder or Dependent Adult Abuse Private Postsecondary School Violence CASE NUMBER: I am the petitioner/respondent in this case, and on (date): the above mentioned parties filed a stipulation in this case. Parties agreed to the terms of the stipulation, but the other party failed to comply with the stipulation as follows: Attached is a completed Order to Show Cause or Notice of Court Hearing form (CH-109, WV-109, SV-109, or EA-109), and I request a hearing within 21 days. I understand that I must have the new Notice of Hearing or Order to Show Cause personally served on the respondent. 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) Approved for Optional Use Form #L-0839 (Rev. . 201) DECLARATION OF DEFAULT/NON-COMPLIANCE CIVIL HARASSMENT/WORKPLACE VIOLENCE/ ELDER OR DEPENDENT ADULT ABUSE/PRIVATE POST-SECONDARY SCHOOL VIOLENCE www.occourts.org For your protection and privacy, please press the Clear This Form button after you are done printing the form. American LegalNet, Inc. www.FormsWorkFlow.com