SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER A TTORNEY OR UNREPRESENTED PARTY (Name, State Bar number, and Address): FOR COURT USE ONLY TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: SUPERIOR COURT OF CALIFORNIA, COUNTY OF PLACER 10820 Justice Center Drive P.O. Box 619072 Roseville, CA 95661-9072 APPELLANT: RESPONDENT: PROPOSED STATEMENT ON APPEAL (INFRACTION) CASE NUMBER: I, _________________________________________________, submit this proposed statement on appeal pursuant to California Rules of Court, Rule 8.916 and declare as follows: Trial in this matter was held on ______________________________. The following is a brief description of what occurred at the trial: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Number of additional pages attached: ________ I declare under the penalty of perjury of the laws of the State of California that the foregoing is true and correct. DATE: ______________________________________ PRINTED NAME ________________________________________ SIGNATURE ________________________________________________________________________________________________________________________________________________________________ Form Adopted for Optional Use California Rules of Court, Rules 8.916 Superior Court of California, County of Placer www.placer.courts.ca.gov Local Form PL-AP003 Effective 08-03-2015 American LegalNet, Inc. www.FormsWorkFlow.com