DECLARATION FOR ASSIGNMENT TO THE NORTHERN BRANCH - DOMESTIC VIOLENCE Local Court Form FL- 17 [New January 2019] Form adopted for Mandatory Use Local Court Rules, 5.2, 6.9. www.sanmateocourt.org ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, Address) TELEPHONE NO: FAX NO.(Optional): MOBILE NO: E-MAIL ADDRESS: ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO Southern Division, 400 County Center, Redwood City, CA 94063 Northern Division, 1050 Mission Road, South San Francisco, CA 94080 PETITIONER: RESPONDENT: DECLARATION FOR ASSIGNMENT TO THE NORTHERN BRANCH DOMESTIC VIOLENCE ACTION CASE NUMBER: I, , hereby declare: That I am the Petitioner Respondent in the above-entitled matter, and that said matter may be properly assigned to the Northern Branch of the above-entitled Court at South San Francisco, California, as provided in the Local Rules 5.2 and 6.9 and Standing Order 18-149 of this Court, for the following reason: is a resident of the City of , within the geographical boundaries of the Northern Branch. I, declare under penalty of perjury that the foregoing is true and correct. Executed on , at , California (date) (city) Dated: (Type or Print Name) (Signature) American LegalNet, Inc. www.FormsWorkFlow.com