ATTACHMENT PB-4052 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address): FOR COURT USE ONLY TELEPHONE NUMBER: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NUMBER (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA COURT ADDRESS: CITY AND ZIP CODE: DIVISION: 191 North First Street San José, California 95113 Probate Division In the Matter of the Application of: PETITION FOR WRIT OF HABEAS CORPUS (RE: QUARANTINE DETENTION) File by Fax CASE NUMBER: TO: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA 1. 2. I, (print your name), am the Petitioner in this matter. This Court has jurisdiction pursuant to Article I, Section 9, of the United States Constitution, Article VI, Section 10 of the California Constitution, and California Penal Code Section 1473. The Petitioner has been ordered quarantined and is being confined by order of the Santa Clara County Health Department or its designee at: (check one) his/her home at (address) -ORa facility, if other than home (address) 3. 4. The Petitioner believes that he/she is being deprived of his/her freedom illegally. The Petitioner believes that his/her confinement is illegal because: 5. 6. The Petitioner requests a court review as provided in California Penal Code Section 1473. The Petitioner requests that confidential health care information that is contained in this petition, subsequent related filings, and subsequent orders be protected from public disclosure. WHEREFORE, Petitioner respectfully requests that this Court (check those that apply): Appoint counsel to represent the Petitioner in the matter. [Do not check, if you have already obtained an attorney.] Allow Petitioner to appear by phone. PB-4052 NEW 7/01/11 PETITION FOR WRIT OF HABEAS CORPUS (RE: QUARANTINE DETENTION) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT PB-4052 GUARDIANSHIP OF (child's name(s)): CASE NUMBER: Enter an order setting a hearing on this Petition for the Santa Clara Health Department to show by what legal authority they quarantined and thus confined Petitioner. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Print Petitioner's Name Here Petitioner to Sign Here If you are currently represented by an attorney, please have attorney date and sign. Date: Print Attorney's Name Here Attorney for Petitioner to Sign Here PROOF OF SERVICE I, the undersigned, declare: 1. I am (choose one): Attorney for Petitioner (Name): Adult Person Other than Petitioner (Name): 2. Server's Declaration I have provided a copy of the petition for Writ of Habeas Corpus to the Office of County Counsel for Santa Clara County (Attorney for Santa Clara County Public Health Department) by the following method: Personal Delivery: Name of person delivered to: Title: Address where delivered to: County of Santa Clara, Office of the County Counsel 70 W. Hedding Street, 9th Floor, East Wing, San José, CA 95110 Fax: Fax attention to: Santa Clara County, Office of County Counsel Fax number: (408) 292-7240 (Please attach a copy of the fax confirmation sheet.) Please provide: Date of Service: Time: I certify under penalty of perjury, that a copy of the petition was served in the manner stated above and that the foregoing is true and correct. Date: Print Server's Name Here Server to Sign Here PB-4052 NEW 7/01/11 PETITION FOR WRIT OF HABEAS CORPUS (RE: QUARANTINE DETENTION) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT PB-4052 GUARDIANSHIP OF (child's name(s)): CASE NUMBER: INSTRUCTIONS 1. Fill out the Petition for Writ of Habeas Corpus. 2. Date and sign the petition under penalty of perjury. 3. Someone 18 or over (not you) must serve a copy of the petition to the Office of the County Counsel for Santa Clara County on behalf of Santa Clara County's Public Health Department. The Court cannot accept your Petition for filing unless you have given notice to Office of County Counsel for Santa Clara County. You can serve Santa Clara County's County Counsel by one of the following methods: x Personal Delivery to: Santa Clara County Office of County Counsel (Please leave it with someone at the front desk but remember to ask for their name and title) Address: County of Santa Clara, Office of the County Counsel 70 W. Hedding Street, 9th Floor, East Wing, San José, CA 95110 -ORx Fax to: Attn: Santa Clara County Office of County Counsel Number: (408) 292-7240 Subject line: Petition for Writ of Habeas Corpus Re: Quarantine 4. The person who served the papers must fill out the proof of service attached to the petition (page 2) indicating how Santa Clara County's County Counsel was served. Please remember to have them date and sign the service declaration under penalty of perjury and keep a copy of all papers submitted to the court for your records. 5. File the petition with the attached signed proof of service at the Probate Clerk's Office. There is no filing fee for this petition. You can file using one of the following methods: x Personal Delivery (other than yourself due to quarantine order) to: Probate Clerk's Office, Room 107 Attn: Probate Deputy Court Manager Address: 191 N. First St., San José, CA 95113 Fax to: Attn: Probate Clerk's Office - Superior Court Deputy Court Manager Number: (408) 882-2694 Subject line: Petition for Writ of Habeas Corpus Re: Quarantine Detention Scan & E-mail to (Note: ALL paperwork must be scanned and sent as an attachment to the e-mail itself): Attn: Probate Clerk's Office- Superior Court Deputy Court Manager E-mail address: quarantinewrit@scscourt.org Subject line: Petition for Writ of Habeas Corpus Re: Quarantine Detention x x 6. You may request an endorsed filed copy for your records. 7. The judge will review your request and notify you of the decision. PB-4052 NEW 7/01/11 PETITION FOR WRIT OF HABEAS CORPUS (RE: QUARANTINE DETENTION) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com