SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BANNING 135 N. Alessandro Rd., Banning, CA 92220 MORENO VALLEY 13800 Heacock St., Ste. D201, Moreno Valley, CA 92553 BLYTHE 265 N. Broadway, Blythe, CA 92225 MURRIETA 30755 - D Auld Road, Suite 1226, Murrieta, CA 92563 CORONA 505 S. Buena Vista Rm. 201, Corona, CA 92882 PALM SPRINGS 3255 E. Tahquitz Canyon Way, Palm Springs, CA 92262 HEMET 880 N. State St., Hemet, CA 92543 TEMECULA 41002 County Center Dr., Ste. 100, Temecula, CA 9251 RI - SC 002 PARTY (Name and Address): FOR COURT USE ONLY TELEPHONE NO.: F AX NO. (Optional): E - MAIL ADDRESS (Optional) ; ATTORNEY FOR ( Name) ; PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: CASE NUMBER: SMALL CLAIMS DECLARATION (CCP247 170.6) I, declare that I am the P laintiff/Petitioner Defendant/Respondent Other: in this action . The Judge/Commissioner: of the above entitled court before whom the trial of the aforesaid action is assigned, is prejudiced against the interest of said party cannot, or he/she believes that he/she cannot, have a fair and impartial trial or hearing before said Judge/Commissioner. I, the undersigned declare under penalty of perjury under the laws of the State of California that I am the judgment debtor and the above statements are true and correct. Date: (SIGNATURE OF DECLARANT) The declaration having been timely filed; the clerk may proceed to send case for re - assignment. The declaration not having been timely filed; the case will not be reassigned . Date: (JUDGE OF THE SUPERIOR COURT) Page 1 of 1 Approved for Optional Use Riverside Superior Court RI - SC 00 2 [Rev. 07/29/13 ] S MALL CLAIMS DECLARATION (CCP247 170.6) Code of Civil Procedure 247170.6 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com