LLA 2017-0004 Parcel A HideawayRECORDING REQUESTED BY
Brent S. Hicks and Jorja D. Hicks
WHEN RECORDED MAIL TO
AND MAIL TAX STATEMENTS TO
Brent S. Hicks and Jorja D. Hicks
80290 Via Capri
La Quinta, CA 92253
GRANT DEED
DOC # 2017-0519775
12/12/2017 11:25 AM Fees: $42.00
Page 1 of 10
Recorded in Official Records
County of Riverside
Peter Aldana
Assessor -County Clerk -Recorder
"This document was electronically submitted
to the County of Riverside for recording—
Receipted by: MARIA #309
�p LLA 2017-0004 : ,
TITLE ORDER N0. / r � t� 7 ESCROW NO 10' 15 APN NO. 777-390-001, 777-390-002,7T7-080-016
rpp
THE UNDERSIGNED GRANTOR(s) DECLARE(s)
DOCUMENTARY TRANSFER TAX is $ !"' -i Sr CITY TAX $ .�
❑ computed on full value of property conveyed, or ❑ computed on full value less value of liens or encumbrances remaining at
time of sate, �p,,� a
[I Unincorporated area: E, City of � LfglAo
,and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Brent S. Hicks and Jorja D. Hicks, Trustees of the Hicks Family Trust dated November 3, 2004
and
ND La Quinta Partners, LLC a Delaware Limited Liability Company
hereby GRANT(s) to
Brent S. Hicks and Jorja D. Hicks, Trustees of the Hicks Family Trust dated November 3, 2004
the following described real property in the City of La Quinta, County of Riverside, State of California:
Parcel "A" of Lot Line Adjustment 2017-0004, approved by the City of La Quinta as depicted on
Exhibits "A" and "B", attached hereto and by this reference made a part hereof.
NOTE: This Grant Deed perfects the intent of Lot Line Adjustment 2017-0004 as approved by the
City of La Quinta.
Hicks Family Trust dated November 3, 2004
0? R /�� Y- T '"17
nt S. icks us a Date
re M -1p )-71 Lf ?/�;r aqf�
a D. Hicks Trustee Date
This Grant Deed reflects Lot Line Adjustment
2017-0004 as Approved by the City of La Quinta,
Bry ' W. McKinney, P.r, Date
Interim City Engineer, RCE No. 49418
ND La Quinta Partners, LLC, A Delaware Limited Liabilitv Coml
Brian Ellis, President
Bri n Ellis, resident w Date
�4wyef.�' vTzr
RECORDING REQUESTED BY
Brent S. Hicks and Jorja D. Hicks
WHEN RECORDED MAIL TO
AND MAIL TAX STATEMENTS TO
Brent S. Hicks and Jorja D. Hicks
80290 Via Capri
La Quinta, CA 92253
GRANT DEED
LLA 2017-0004 -1Q: ev 160
TITLE ORDER NO. &6_0 5 ESCROW NOPQL 1515% APN NO. 777-390-001, 777-390-002,777-080-016
THE UNDERSIGNED GRANTOR(s) DECLARE(s)
DOCUMENTARY TRANSFER TAX is $ Z .-1 .5— CITY TAX $
❑ computed on full value of property conveyed, or ❑ computed on full value less value of liens or encumbrances remaining at
time of sale,
El Unincorporated area: Q City of ��/ // 1X and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Brent S. Hicks and Jorja D. Hicks, Trustees of the Hicks Family Trust dated November 3, 2004
and
ND La Quinta Partners, LLC a Delaware Limited Liability Company
hereby GRANT(s) to
Brent S. Hicks and Jorja D. Hicks, Trustees of the Hicks Family Trust dated November 3, 2004
the following described real property in the City of La Quinta, County of Riverside, State of California:
Parcel "A" of Lot Line Adjustment 2017-0004, approved by the City of La Quinta as depicted on
Exhibits "A" and "B", attached hereto and by this reference made a part hereof.
NOTE: This Grant Deed perfects the intent of Lot Line Adjustment 2017-0004 as approved by the
City of La Quinta.
Hicks Familv Trust dated November 3, 2004
e' •2.0/7
Bent S. icks us e Date
J0 07
�Y�
ja D. Hicks, Trustee Date
This Grant Deed reflects Lot Line Adjustment
2017-0004 as Approved by the City of La Quinta.
r
Bryaf(W. McKinney, P.E., Date
Interim City Engineer, RCE No. 49418
ND La Quinta Partners. LLC. A Delaware Limited Liabilitv Compan
Brian Ellis, President
)-A-A
ld �9
Brian Ellis, President Date
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
�1S VA v
State of�ia °)
County of NAV -y- )
On 'V 1 before me,
(insert name and title of the officer)
personally appeared _bY'MA- k"(."
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
-tj4b*Acsn,J
I certify under PENALTY OF PERJURY under the laws of the State of�hat the foregoing
paragraph is true and correct.
ALEXANDRIA LEE
WITNESSy hand and official seal. Notary Public
I State of Washington
My Appointment Expires
rl -May 15, 2021
Signatu
(Seal)
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validitv of that document.
r.
County of CX I F1 VTTTFC1
"AA un
Ony �. �u `� before me, m I w L\/ U b C
LO (insert name and title of the offi er)
personally appeared 413144 �OV�R'
who proved to me on the bas's of satisfact ry evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
r.J*'rwvd
1 certify under PENALTY OF PERJURY under the laws of the State ofd that the foregoing
paragraph is true and correct.
ALEXANDRIA LEE
WITNESS ml hand and official seal. Notary Public
State of Washington
My Appointment Expires
May 15, 2021
Signature 4-k- (Seal)
PENALTY OF PERJURY FOR NOTARY SEAL
(GOVERNMENT CODE 27361.7)
I certify under penalty of perjury that the Notary Seal on the document to
which this statement is attached reads as follows:
NAME OF NOTARY: ALEXANDRIA LEE
DATE COMMISSION EXPIRES: MAY 1 S, 2021
COUNTY WHERE BOND IS FILED (if applicable): CLARK
STATE WHERE BOND IS FILED: WASHINGTON
COMMISSION NUMBER (if applicable): NOT -SET -OUT
PLACE OF EXECUTION: RIVERSIDE, CALIFORNIA
(CITY & STATE)
DATE: November 2, 2017
-,M0/ ,4011I
PRINT NAME: SCOTTA. HOOGERWERF
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of (Z-%VQ�y-xj cLP— )
On k rn her 2'S , oL-:before me, l�2 rfe..i`r� tib r0V
(ins�e and title of the officer)
personally appeared t � • ►C '
who proved to me on the baNA of satisfactory evidence to be the pbrson("hose named Fare
subscribed to the within instrument and acknowledged to me that e/ he/they executed the same in
,
/her/their authorized capacity(i , and that by er/their signature.(s}-on the instrument the
person;( , or the entity upon behalf of which the persoDke�acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
An�Signatu e
ANGELA FERREIRA
Commission # 2104060
Notary Public - California n
Z ' �.
Riverside County
(Seal)
PENALTY OF PERJURY FOR NOTARY SEAL
(GOVERNMENT CODE 27361.7)
I certify under penalty of perjury that the Notary Seal on the document to
which this statement is attached reads as follows:
NAME OF NOTARY: ANGELA FERREIRA
DATE COMMISSION EXPIRES: APRIL 17, 2019
COUNTY WHERE BOND IS FILED (if applicable): RIVERSIDE
STATE WHERE BOND IS FILED: CALIFORNIA
COMMISSION NUMBER (if applicable): 2104060
PLACE OF EXECUTION: RIVERSIDE, CALIFORNIA
DATE: Novel
SIGNATURE:
(CITY & STATE)
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of116
oh 1 6
County of 'Girl �� ! r )
On before me, L -9-cyfonod
(insert narab and title of the officer)
personally appeared Y a n T�-7 1 S
who proved to me on the basis of satisfactory evidence to be theerson(s) whose name(s is rare
subscribed to the within instrument and acknowledged to me tha heVshe/they executed the me in
ishis/her/their authorized capacity(ies), and that by her/their signa ure(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the
paragraph is true and correct.
WITNESS my
Signatu
and official seal.
(Seal)
iat the foregoing
Shelley L, Stevens
Notary Public, State of Ohio
My Commiskri F fres 1014
PENALTY OF PERJURY FOR NOTARY SEAL
(GOVERNMENT CODE 27361.7)
I certify under penalty of perjury that the Notary Seal on the document to
which this statement is attached reads as follows:
NAME OF NOTARY: SHELLEY L. STEVENS
DATE COMMISSION EXPIRES: OCTOBER 31, 2017
COUNTY WHERE BOND IS FILED (if applicable): FRANKLIN
STATE WHERE BOND IS FILED: OHIO
COMIVIISSION NUMBER (if applicable): NOT -SET -OUT
PLACE OF EXECUTION: RIVERSIDE, CALIFORNIA
DATE: Novel
SIGNATURE:
(CITY & STATE)
WERF
EXHIBIT "A"
LEGAL DESCRIPTION
CERTIFICATE OF LOT LINE ADJUSTMENT 2017-0004
PARCEL "A"
That certain parcel of land located in the City of La Quinta, County of Riverside, State of
California, being all of Lot 39 and all of Lot 40 of Tract No. 29894-3 as shown by a map
on file in Book 351, Pages 35 through 48, inclusive, of Maps, Records of said County
together with that portion of "Lot H -Golf Course" of said Tract No. 29894-3, more
particularly described as follows:
BEGINNING at the southwest corner of said Lot 39;
Thence along the southerly line of said Lot 39 North 83018'41" East a distance of 70.12
feet to the southerly corner common to said Lots 39 and 40;
Thence along the southerly line of said Lot 40 South 80°03'08" East a distance of 69.91
feet to the southeast corner of said Lot 40;
Thence leaving said southerly line of Lot 40 North 88022'59" West a distance of 138.56
feet to the POINT OF BEGINNING.
CONTAINING: 36,260 Square Feet (0.75 Acres), more or less.
SUBJECT TO all Covenants, Rights, Rights -of -Way and Easements of record.
Graphically depicted on `EXHIBIT "B" — PLAT', attached hereto and by this
reference made a part hereof.
This Legal Description reflects Certificate of Lot Line Adjustment No. 2017-0004,
as approved by the City of La Quinta.
This document also is also recorded to correct the words "Tract No. 29494-3" to
"Tract No. 29894-3" in the City of La Quinta Certificate of Parcel Merger No. 2017-
0001 recorded April 11, 2017 as Doc. #2017-0144285 of Official Records.
This legal description was prepared
by me or under my direction.
�tk t L A rV
Benjamin Daniel Egan, PLS 8756
Prepared: September 25, 2017 \ � 7561
IL k t
S4 F� �Gv P TO 0
& y�P
VIA MONTECfi
SITE _N
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a g
EXHIBIT "B" 20 0 40
6?qi-m"
PLAT SCALE: 1"=40'
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,
ry AVENUE 54 I
`IUNITY MAP P
CERTIFICATE OF
PARCEL MERGER
2017-0001 REC.
04/11/2017 AS DOC.
#2017-0144285.
PARCEL "A"
32,620± SQUARE FEET
0.75± ACRES
� D' .
iii
J
Q
U
L7
6' ( LOT 39) ( LOT 40) `�'
» » (TRACT 29894-3) (TRACT 29894-3)
PARCEL B (MB 351/35-48) (MB 351/35-48)
ADJUSTED LOT "H"
P.O.B. (LOT 41)
SW CORNER LOT LINE TO (TRACT 29894-3)
LEGEND: LOT 39 BE DELETED (MB 351/35-48)
= EXISTING LOT LINE (N83'18�41_E 70.12') (S80°03 0= 6_91 )
DELETED LOT LINE N88°22'59"W 138.56'
BOUNDARY OF PARCEL �� �� ��
ADJUSTED PARCEL B
() DENOTES RECORD DATA LOT LINE ADJUSTED LOT "H"
PER MB 351/35-48 SHEET 1 OF 1
CERTIFICATE OF LOT LINE ADJUSTMENT 2017-0004
PREPARED BY:
�P� SAND
5�\���N D A
o<vW�Q. Fy
G
m Z o
N 0. 8756
s Q
BENJAMIN DANIEL EGAN , PLS �qrF OF CA
LS 8756 DATE: 9/25/2017
BOE -502-A (P1) REV, 12 (05-13)
PRELIMINARY CHANGE OF OWNERSHIP REPORT
To be completed by the transferee (buyer) prior to a transfer of subject
property, in accordance with section 480,3 of the Revenue and Taxation
Code. A Preliminary Change of Ownership Report must be fled with each
conveyance in the County Recorder's office for the county where the
property is located.
NAME AND MAILING ADDRESS OF BUYERITRANSFEREE
(Make necessary corrections to the printed name and mailing address)
V tc--
lA Q.-2.- �i ZZ S3
L -
STREETADDRESS OR PHYSICAL LOCATION OF REAL PROPERTY
MAIL PROPERTY TAX INFORMATION TO (NAME)
PETER ALDANA, COUNTY OF RIVERSIDE
ASSESSOR - COUNTY CLERK - RECORDER
PO BOX 751, RIVERSIDE, CA 92502-0751
(951) 955-0400 www,riversideacr.com
�'-)7p -
61�2 r
ASSESSOR'S PARCEL NUMBER
SELLERrrRANSFEROR
BUYERS DAYTIME TELEPHONE NUMBER
l
—1 BUYER'S EMAILADDRESS
ZIP
❑YES �JO This property is intended as my principal residence. If YES, please indicate the date of occupancy MO DAY YEAR
or intended occupancy.
PART 'I. TRANSFER INFORMATION Please complete all statements.
This section contains possible exclusions from reassessment for certain types of transfers.
YES NO
❑ A. This transfer is solely between spouses (addition or removal of a spouse, death of a spouse, divorce settlement, etc.).
❑ B, This transfer is solely between domestic partners currently registered with the California Secretary of State (addition orremoval of
a partner, death of a partner, termination settlement, etc.).
❑ El * C. This is a transfer: ❑ between parent(s) and child(ren) ❑ from grandparent(s) to grandchild(ren),
❑ E I * D. This transfer is the result of a cotenant's death. Date of death
❑ * E. This transaction is to replace a principal residence by a person 55 years of age or older.
Within the same county? ❑ YES ❑ NO
❑EJ * F. This transaction is to replace a principal residence by a person who is severely disabled as defined by Revenue and Taxation Code
section 69.5. Within the same county? ❑ YES ❑ NO
❑ G. This transaction is only a correction of the name(s) of the person(s) holding title to the property (e.g., a name change upon marriage).
If YES, please explain:
❑ H. The recorded document creates, terminates, or reconveys a lenders Interest in the property.
❑ 1. This transaction is recorded only as a requirement for financing purposes or to create, terminate, or reconvey a security interest
(e -g., cosigner). If YES, please explain:
❑ J. The recorded document substitutes a trustee of a trust, mortgage, or other similar document.
K. This is a transfer of property:
❑ ❑ 1. tolfrom a revocable trust that may be revoked by the transferor and is for the benefit of
❑ the transferor, and/or ❑ the transferor's spouse ❑ registered domestic partner.
❑ ❑ 2. tolfrom a trust that may be revoked by the creator/grantor/trustor who is also a joint tenant, and which
names the other joint tenant(s) as beneficiaries when the creator/grantorltrustor dies.
❑ ❑ 3. to/from an irrevocable trust for the benefit of the
❑ creator/grantorltrustor and/or ❑ grantor's/trustor's spouse ❑ grantor's/trustor's registered domestic partner.
❑ ❑ L. This property is subject to a lease with a remaining lease term of 35 years or more including written options.
❑ ❑ This is a transfer between parties in which proportional interests of the transferor(s) and transferee(s) in each and every parcel
being transferred remain exactly the same after the transfer.
❑ ❑ N. This is a transfer subject to subsidized low-income housing requirements with governmentally imposed restrictions.
❑ ❑ * O. This transfer is to the first purchaser of a new building containing an active solar energy system.
* Please refer to the instructions for Part 1.
Please provide any other information that will help the Assessor understand the nature of the transfer.
THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION
BOE -502-A (P2) REV. 12 (05-13)
PART 2. OTHER TRANSFER INFORMATION
A. Date of transfer, if other than recording date:
B. Type of transfer:
Check and complete as applicable.
U-P"urchase ❑ Foreclosure ❑ Gift ❑ Trade or exchange ❑ Merger, stock, or partnership acquisition (Form BOE -100-B)
❑ Contract of sale. Date of contract: ❑ Inheritance. Date of death:
❑ Sale/leaseback ❑ Creation of a lease ❑ Assignment of a lease ❑ Termination of a lease. Date lease began:
❑ Other. Please explain:
C. Only a partial interest in thi
PART 3. PURCHASE PRICE AND TERMS OF SALE
A. Total purchase price
Check and complete as applicable.
$ V
Amount $
Amount $
B. Cash down payment or value of trade or exchange excluding closing costs
C. First deed of trust @ °!o interest for years. Monthly payment $
❑ FHA (Discount Points) ❑ Cal -Vet ❑ VA (_Discount Points) ❑ Fixed rate ❑ Variable rate
❑ Bank/savings & Loan/Credit Union ❑ Loan carried by seller
❑ Balloon payment $ Due date:
D. Second deed of trust @ % interest for years. Monthly payment $
❑ Fixed rate . ❑ Variable rate ❑ Bank/Savings & Loan/Credit Union ❑ Loan carried by seller
❑ Balloon payment $ Due date:
Amount $
E. Was an Improvement Bond or other public financing assumed by the buyer? ❑YES ❑ NO Outstanding balance $
F. Amount, if any, of real estate commission fees paid by the buyer which are not included in the purchase price $
G, The property was purchased: ❑Through real estate broker, Broker name: Phone number: {
❑ Direct from seller ❑ From a family member -Relationship
❑ Other. Please explain:
H. Please explain any special terms, seller concessions, broker/agent fees waived, financing, and any other information (e.g., buyer assumed the
existing loan balance) that would assist the Assessor in the valuation of your property.
PART 4. PROPERTY INFORMATION Check and complete as applicable.
A. Type of property transferred
❑ Single-family residence ❑ Co-op/Own-your-own ❑ Manufactured home
❑ Multi I -family residence. Number of units: ❑ Condominium ❑ Unimproved lot
ttherDescription: (i.e., timber, mi eral, water rights, etc.) ❑ Timeshare ❑ Commercial/industrial
B. ❑YES ❑ NO Personal/business property, or incentives, provided by seller to buyer are included in the purchase price. Examples of personal
property are furniture, farm equipment, machinery, etc. Examples of incentives are club memberships, etc. Attach list if available.
If YES, enter the value of the personal/business property: $ Incentives $
C. ❑YES ❑ NO A manufactured home is included in the purchase price.
If YES, enter the value attributed to the manufactured home: $
❑YES ❑ NO The manufactured home is subject to local property tax. if NO, enter decal number:
D. ❑YES ❑ NO The property produces rental or other income.
If YES, the income is from: ❑ Lease/rent ❑ Contract ❑ Mineral rights ❑ Other:
E. The condition of the property at the time of sale was: [—]Good ❑Average ❑Fair ❑Poor
Please describe:
CERTIFICATION
1e declaCe) that the foregoing and all information hereon, including any accompanying statements or documents, is true and correct to
t
e b Ry knowledge and belief.
SI NAT E ORATE OFFICER DATE TELEPHONE
NAM RrrRANSFEREE/LEOAL REPRESENTATIVE/CORPORATE OFFICER (PLEASE PRINT) TITLE EMAILADDRESS
The Assessor's office may contact you for additional information regarding this transaction.
2.
3,
4.
5,
6.
7.
.ar ttrWEQSi Recorder
°�. PETER ALDANA P.O. Box 751
COUNTY OF RIVERSIDE Riverside, CA 92562-0751
o ASSESSOR -COUNTY CLERK -RECORDER (951) 486-7000
Website: Nvzvw.riversideacr.com
CDOCUMENTARY TRANSFER TAX AFFIDAVIT
EMIT91TIN MLI
ANY PERSON WHO MAKES ANY MATERIAL MISREPRESENTATION OF FACT FOR THE PURPOSE OF AVOIDING ALL OR ANY PART
OF THE DOCUMENTARY TRANSFER TAX IS GUILTY OF A MISDEMEANOR UNDER SECTION 5 OF ORDINANCE 516 OF THE COUNTY
OF RIVERSIDE AND IS SUBJECT TO PROSECUTION FOR SUCH OFFENSE.
ASSESSOR'S PARCEL NOI-11 --390 -- o c:)( I declare that the documentary transfer tax for this
Pro e Address'
3�to- ooZ 'iZe -uSo- o I� transaction is: $ Z�{.1 S
�lI/ 7� Pte -
If this transaction is exeitipf from Documentary ransfer Tae reasonst' ll�e iientified below.
I CLAIM THAT THIS TRANSACTION IS EXEMPT FROM DOCUMENTARY TRANSFER TAX BECA USE: (The
Sections listed below are taken front the Revenue and Taxation Code with the exception of itents 9 and 10 whicli are taken
front Riverside County Ordinance 516). Please check one or explain in "Other':
Section 11911. The consideration or value of the property, exclusive of any liens and encumbrances is
$100.00 or less and there is no additional consideration received by the grantor.
Section 11911. The conveyance transfers to a revocable living trustby-flie grantor or from a revocable living
trust to a beneficiary. '
Section 11921. The conveyance was given to secure a t.
^_Section 11922. The conveyance is to a governor a entity or political subdivision.
vSection 11925. The transfer is between indtvf'c uals and a legal entity or partnership, or between
legal entities and doet change the proportional interests held.
Section 11926. The conveyance' o a grantee who is the foreclosing beneficiary and the consideration paid by
the foreclos' eneficiary does not exceed the unpaid debt.
Section 11927. The co yance relates to a dissolution of marriage or legal separation.
(A s se must sign a written recital in order to claim this exemption. This form may be used for that purpose.)
Section 11930. e conveyance is an inter vivos gift* or a transfer by death.
�Piease be aware that information stated on this document may be given to and used by governmental
agencies, including the Internal Revenue Service. Also, certain gifts in excess of the annual Federal gift tax
exemption may trigger a Federal Gift Tax. To such cases, the Transferor (donor/grantor) maybe required to
file Form 709 (Federal Gift Tax Return) with the Internal Revenue Service.
Se ion 8. The easement is MaLperpetual, permanent, or for life.
ection 9. The document is a lease for a term of JULthan (35) ears (including written options.)
Other (Include explanation and legal authority) (� L llr��
Go \t tet'^- NA--
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT,
Executed this L— day of 20 t 1 at
City State
Signature of Affiant Printed Name of Affiant
LA- -C_, -ric7\to L— -.hew. 'S� X31 b 1
Name of Firm (if applicable) Address of Affiant (including City, Srate, and Zip Code)
'11(w0 - 5i 4 - -J-o9Z
Telephone Number of Affiant (including area code)
For Recorder's Use:
This form is subject to the California Public Records Act (Government Code 6250 et, seq.)
Affix POOR Label Here
ACR 521 (Rev. 11/2014) Available in Alternate Formats