ATTACHMENT CV-5058 ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS) TELEPHONE NUMBER: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER: RESPONDENT: OTHER PARTY: 191 North First Street San José, California 95113 STIPULATION AND ORDER Modification 1. Not based on a hearing Today's Hearing (date) CASE NUMBER: DEPARTMENT: 2. Judge: 3. Parties/Attorneys: Petitioner present in court Respondent present in court Other party present in court Petitioner's attorney present: Respondent's attorney present: Other party's attorney present: Do not use this form for Civil Harassment Restraining Order after Hearing. Those orders must be made on form CH-130. In addition, do not use this form for Continuance and Reissuance. Those orders must be made on form CH-116. 4. The parties agree that the Court will make orders about the following items: Other orders: Attorney's fees and costs: See Attachment See Attachment Not Applicable Not Applicable Petitioner Respondent CV-5058 REV 02/10/12 STIPULATION AND ORDER Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT CV-5058 PETITIONER: RESPONDENT: CASE NUMBER: We have read this entire Stipulation and Order, including all Attachments. We understand it fully and ask that the Court make our stipulation the Court's orders. We give up the right to all further notice of this order. Date: Petitioner Date: Attorney for Petitioner Date: Respondent Date: Attorney for Respondent Date: Other party: Date: Attorney for Other party: Interpreter Witness Declaration Interpreter: The Petitioner Respondent Stipulation and Order and its attachments because: a. b. his/her primary language is (specify): other (specify): Other party is unable to read or understand this I certify under penalty of perjury under the laws of the State of California that I have, to the best of my ability, read or Petitioner Respondent Other party this Stipulation and Order including all translated for the attachments. He or she said they understood this Stipulation and Order and its attachments before signing them. Date Interpreter's printed name Interpreter's signature ORDER The Court approves the terms stipulated and agreed to by the parties in this document and makes them court orders. Date: Judicial Officer of the Superior Court Petitioner Respondent CV-5058 REV 02/10/12 STIPULATION AND ORDER Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com