NAME OF COURT: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SHASTA Mailing Address 1500 Court Street, Room 319 Street Address Juvenile Division, Dependency Unit Redding, CA 96001 Branch Name: Redding In the Matter of: NOTIFICATION OF LAST KNOWN ADDRESS ADDRESS CHANGE AND ORDER Case Number: I, _______________________________________________________ (Name of clerk/case worker/attorney etc. making declaration) ________________________________ (Title) was informed on ________________________________ that ________________________________________ (Date) (Name of Party) a party in the above entitled action, has relocated to the following address for mail delivery : _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ I received this information from the following source: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. ______________________________________________________ Signature of Declarant ORDER ________________________________ Date The above address is designated as the last known address for _________________________________________ Date: ____________________________ ________________________________________ Judge (Original to Juvenile Unit, Superior Court of Shasta County) ______________________________________________________________________________________ Form Approved for Optional Use Shasta County Superior Court LF-JUV-100 [rev July 1, 2012] NOTIFICATION OF LAST KNOWN ADDRESS/ADDRESS CHANGE Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com