ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & 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 700 Civic Center Dr. West, Santa Ana, CA 92701-4045 JUSTICE CENTER: APPELLANT: RESPONDENT: NOTICE OF APPEAL ­ CIVIL CITATION CASE NO: Civil Citation fine/penalty has been paid. has been waived by the citing agency. Contestant/Appellant, , of the above entitled action, having exhausted the administrative review process, hereby appeals to the Superior Court of California, County of Orange from the final decision of the administrative review, which was mailed or personally served on , regarding Civil Citation number: . 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 APPELLANT OR ATTORNEY) NOTE: A separate appeal must be filed for each civil citation. A copy of this document must be mailed to the citing agency. The original appeal with proof of service must be filed with the court with the proper filing fee. PROOF OF SERVICE BY MAIL I deposited a copy of the Notice of Appe al in the United St ates mail, in a sealed envelope with postage fully prepaid. The envelope was addressed as follows: (Name and address of citing agency) Date of mailing: Place of mailing (city and state): . I am a resi dent of or empl oyed in the county whe re the Notice of Appeal was mailed. My residence or business address is: Street Address: City: State: . 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) Approved for Optional Use L-1044 (Rev. July 2013) ________________________ NOTICE OF APPEAL - CIVIL CITATION Govt. Code § 53069.4 www.occourts.org American LegalNet, Inc. www.FormsWorkFlow.com (SIGNATURE OF DECLARANT)