FOR COURT USE ONLY CONFLICT AND ACCOUNTABLITY PROGRAM PROVIDER (Name and Address): TELEPHONE NO: FAX NO. (Optional): E-MAIL ADDRESS (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: 170 Park Avenue MAILING ADDRESS: 191 North First Street CITY AND ZIP CODE: BRANCH: San Jose, California 95113 Park Avenue Courthouse – Family ANNUAL DECLARATION UNDER PENALTY OF PERJURY CONFLICT ACCOUNTABILITY , do hereby declare under penalty of perjury that I and I, Name of Professional Provider everyone I employ as a provider of Conflict and Accountability agree to abide by the standards for structure and content as published on September 16, 2008 by the Conflict and Accountability Task Group, a subcommittee of the DV Court Systems Committee. This publication is attached and available on the Court’s website at www.sccsuperiorcourt.org. Name of Provider: Address of Provider: Name of Signatory: Signature of Signatory: Date: Please send completed original form to: FM-1084 REV 9/2/09 Superior Court of California, County of Santa Clara Attn: Family Court Services 191 North First Street, San Jose, CA 95113 ANNUAL DECLARATION UNDER PENALTY OF PERJURY CONFLICT ACCOUNTABILITY Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com