Los Angeles Regional Office Glendale, CA 9120Phone: (818) 551-2822 Fax: (818) 551-2820 PERBe-file.LARO@perb.ca.gov Sacramento Regional Office 1031 18th Street Sacramento, CA 9581-414 Phone: (916) 322-3198 Fax: (916) 327-6377 PERBe-file.SRO@perb.ca.gov San Francisco Regional Office 1330 Broadway, Suite 1532 Oakland, CA 94612-2514 Phone: (510) 622-1016 Fax: (510) 622-1027 PERBe-file.SFRO@perb.ca.gov Revised /1 MMBA Factfinding Request MMBA FACTFINDING REQUEST DO NOT WRITE IN THIS SPACE: Case No.: Date Filed: INSTRUCTIONS: A request for factfinding pursuant to Government Code section 3505.4 must be filed with the appropriate regional office (see PERB Regulation 32075). Proof of service must accompany the request. 1. EMPLOYER Name:Address: Agent to be contacted: Name: Title: Agency/Law Firm: Address: Phone: E-mail Address: 2. EXCLUSIVE REPRESENTATIVE Name:Address: Agent to be contacted: Name: Title: Union/Law Firm: Address: Phone: E-mail Address: 3.TITLE/DESCRIPTION OF ESTABLISHED UNIT 4.TYPE OF DISPUTE (e.g., initial contract, successor contract, reopeners) STATUS OF NEGOTIATIONS/MEET AND CONFERDate impasse:Date a mediator was appointed (if applicable): DECLARATION The parties have been unable to effect a settlement. Therefore, pursuant to PERB Regulation 32802, we request that the parties222 differences be submitted to a factfinding panel. NAME OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AUTHORIZED REPRESENTATIVE: Title: Date: (Attach a completed Proof of Service form.) American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE I declare that I am a resident of or employed in the County of , State of . I am over the age of 18 years. The name and address of my residence or business is: On , I served the (Date) (Describe document(s)) (Description of document(s) continued) on the parties listed below (include name, address and, where applicable, fax number) by (check the applicable method or methods): placing a true copy thereof enclosed in a sealed envelope for collection and delivery by the United States Postal Service or private delivery service following ordinary business practices with postage or other costs prepaid; personal delivery; facsimile transmission in accordance with the requirements of PERB Regulations 32090 and 32135(d). (Include here the name, address and, where applicable, fax number of the Respondent and any other parties served.) I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed on , at , (Date) (City) . (State) (Type or print name) (Signature) American LegalNet, Inc. www.FormsWorkFlow.com