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MC-350 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (The Superior Court of California - County of Orange)

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MC-350
FOR COURT USE ONLY
CASE NUMBER:
CASE NAME:
HEARING DATE:
PETITION TO APPROVE:
DEPT.: TIME:
Person With a DisabilityMinor
Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor,
(2) the compromise of a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a
party, or (3) the disposition of the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob.
Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or
examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment,
and hospitalization. The court may consider on an expedited basis without a hearing requests for approval of the compromises of
certain claims and actions or the disposition of the proceeds of certain judgments. If your claim, action, or judgment qualifies for
expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule
7.950.5.
Petitioner (name):
Claimant (name):
Address:
Date of birth: Age: Sex: e.
Minor Person with a disability
Relationship Petitioner's relationship to the claimant (check all applicable boxes):
Page 1 of 10
Form Adopted for
Alternative Mandatory Use
Judicial Council of California
MC-350 [Rev. January 1, 2011]
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
FAX NO. (Optional):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
Code of Civil Procedure, § 372 et seq.;
Probate Code, § 3500 et seq.;
Cal. Rules of Court, rules 3.1384,
7.101, 7.950, 7.951
www.courts.ca.gov
TELEPHONE NO.:
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
a.
b.
c.
d.
e.
f.
COMPROMISE OF PENDING ACTION
DISPOSITION OF PROCEEDS OF JUDGMENT
1.
2.
a.
b. c. d.
Parent
Guardian ad litem
Guardian
Conservator
(If you checked item 3e or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate
Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not
have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.)
g.
Disabled adult claimant is a petitioner. (See instructions for items 3e and 3f below.)
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 3f.
Other relationship (specify:)
The claim of the minor or adult person with a disability:
Case no.: Trial date: (Complete items 5–23.)
Name of court:
Has not been filed in an action or proceeding. (Complete items 5–23.)
Is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
a.
b.
COMPROMISE OF DISPUTED CLAIM
NOTICE TO PETITIONERS:
4. Nature of claim
3.
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
end of the form when
finished.
CASE NAME:
CASE NUMBER:
Page 2 of 10
MC-350 [Rev. January 1, 2011]
4.
Nature of claim
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13–23.)
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
c.
The judgment was filed on (date):
Is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against
the defendants named below in the total amount (exclusive of interest and costs) of (specify below):
Defendants (names)
$
Continued on Attachment 7.
Continued on Attachment 8.
7.
8.
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe):
Continued on Attachment 6.
6.
The claim of the minor or adult person with a disability:
Place:
Persons involved (names):
5.
Continued on Attachment 5.
a. Date and time:
b.
c.
Incident or accident The incident or accident occurred as follows:
Additional defendants listed on Attachment 4.
CASE NAME:
CASE NUMBER:
Page 3 of 10
MC-350 [Rev. January 1, 2011]
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
a.
9.
The claimant has recovered completely from the effects of the injuries described in item 7, and there are no
permanent injuries.
Extent of injuries and recovery
The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries):
b.
Continued on Attachment 9b.
The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries):
c.
Continued on Attachment 9c.
10. Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or
accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Petitioner fully understands that if the compromise proposed in this
petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further
recovery of compensation from the settling defendants named below even though the claimant's injuries may in
the future appear to be more serious than they are now thought to be.
Amount and terms of settlement
By way of settlement, the defendants named below have offered to pay the following sums to the claimant:
Amounts
Defendants (names)
The terms of settlement are as follows (if the settlement is to be paid in installments, both the total amount and the
present value of the settlement must be included):
Continued on Attachment 11.
11.
Defendants and amounts offered continued on Attachment 11.
$
$
$
$
$
a.
b.
The total amount offered by all defendants named below is (specify): $
The defendants and amounts offered by each are as follows (specify):
c.
(An original or a photocopy of all doctors' reports containing a diagnosis of and prognosis
for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 9.
A new report is not necessary so long as a previous report accurately describes the claimant's current condition.)
CASE NAME:
CASE NUMBER:
Page 4 of 10
MC-350 [Rev. January 1, 2011]
13.
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
Settlement payments to others
a.
12.
No defendant named in item 11b has offered to pay money to any person or persons other than the claimant to
settle claims arising out of the same incident or accident that resulted in the claimant's injury.
b. By way of settlement, one or more defendants named in item 11b have also offered to pay money to a person or
persons other than claimant to settle claims arising out of the same incident or accident that resulted in the
claimant's injury.
The total amount offered by all defendants to others (specify): $
Petitioner would receive money under the proposed settlement.
(1)
(2)
Amounts
Other plaintiffs or claimants (names)
Additional plaintiffs or claimants and amounts are listed on Attachment 12.
$
$
$
$
The settlement payments are to be apportioned and distributed as follows:
(3)
(4)
(5)
Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 12.
Petitioner
is not is a claimant against the recovery of the claimant (other than for
reimbursement for expenses paid by petitioner and listed under item 15).
(If you answered "is," explain in Attachment 12 the circumstances and the effect your claim has on the
proposed compromise of the claim described in this petition.)
Petitioner is not is a plaintiff in the same action with the claimant.
(If you answered "is," explain in Attachment 12 the circumstances and the effect your claim and its disposition
has on the proposed compromise of the claim or action described in this petition.)
(6)
Total outstanding medical expenses to be paid from the proceeds:
Total out-of-pocket, co-payments, or deductible payments to be reimbursed from proceeds:
a. Totals
(1)
(2)
(3)
$
$
(1)
(2)
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
Paid by petitioner in the amount of:
Paid by private health insurance or a self-funded plan under:
No reimbursement is requested by the plan.
(a)
(b)
(c)
(d)
(e)
(f)
(i)
(ii)
Reimbursement is to be made to the plan and:
(A)
(B)
(C)
There is a contractual reduction of $ (
$
for a total reimbursement to the plan in the amount of:
)
$
There is a negotiated reduction of $ (
)
No reduction has been agreed to,
Total medical expenses: $
An Employee Retirement Income Security Act (ERISA) insured plan.
An ERISA self-funded plan.
A Non-ERISA insured plan.
A Non-ERISA self-funded plan.
Amount paid by plan: $
Amount of reimbursement to the plan from proceeds of settlement or judgment:
CASE NAME:
CASE NUMBER:
MC-350
Page 5 of 10MC-350 [Rev. January 1, 2011]
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
(a)
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(4)
Paid by Medi-Cal in the amount of $
(a)
(b)
In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $
(Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 13b(4).)
Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code
section 14124.76 and:
The amount of the lien in dispute is: $
(i)
(ii)
Is filing a motion seeking a reduction of the lien concurrently with this petition.
Requests that the court reserve jurisdiction over this issue.
(5)
$of their lien claims, the lienholders have agreed to accept the total sum of:
13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
Notice of this claim or action has not been given to the State Director of Health Care Services.
(Explain why notice has not been given in Attachment 13b(4).)
and Institutions Code section 14124.73. A copy of the notice and proof of its delivery is attached.
was filed in this matter on (date):
(d)
(c)
(Provide requested information on each lienholder and certain other medical service providers below.)
(3)
Paid by Medicare in the amount of: $
less the statutory reduction in the amount of: $ (
)
for a total reimbursement to Medicare in the amount of:
$
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(3).)
The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all
or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner for which petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any;
and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows:
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
(i) Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
(b)
Continued on Attachment 13b(5). (Provide information about additional providers in the above format,
including providers paid or to be paid by petitioner for which reimbursement is requested in item 13b(1)
above. You may use form MC-350(A-13b(5)) for this purpose.)
Amount charged:
Amount paid (whether or not by insurance):
Negotiated reduction, if any:
(ii) Provider (name):
Address:
Amount to be paid from proceeds of settlement or judgment:
(A)
(B)
(C)
(D)
(E)
(F)
$
$ (
$ (
$
)
)
There are one or more statutory or contractual liens of medical service providers for payment of medical
expenses. The total amount claimed under these liens is: $ . In full satisfaction
Page 6 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
$
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement or judgment
Items
Payees (names) Amounts
Continued on Attachment 14b.
14.
The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment:
a.
b.
Total amount of attorney's fees for which court approval is requested: $
$
$
$
$
$
$
$
$
$
$
$
Total: $
(If fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request, including
a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. Respond to item 18a(2) on page 7 and
attach a copy of any written attorney fee agreement as Attachment 18a.)
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
16.
$
Net balance of proceeds for the claimant
after payment of all requested fees and expenses is:
15. Reimbursement of expenses paid by petitioner
Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested.
a.
b.
Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses for which
reimbursement is requested.
(1)
(2)
(3)
$
$
$
Total: $
Medical expenses listed in item 13:
Attorney's fees included in the total fee amount shown in item 14a:
Other expenses included in the total shown in item 14b:
(Attach proofs of the expenses incurred and payments made or obligations to pay incurred, e.g., bills or invoices,
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
17. Summary
Gross amount of proceeds of settlement or judgment for claimant:
Expenses (other than medical) to be paid from proceeds
of settlement or judgment:
Medical expenses to be paid from proceeds of settlement
or judgment:
Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (e) from (a)):
a.
Attorney's fees to be paid from proceeds of settlement or
judgment:
e.
b.
c.
d.
f.
$
$ (
$
Total of fees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c), and (d)):
$
$
$
)
Page 7 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
Information about attorney representing or assisting petitioner
a. Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with
respect to the claim asserted. (Go to item 19.)
(2)
The attorney who has represented or assisted petitioner is (name):
Telephone number:
The attorney
has not has received attorney's fees or other compensation in addition to that requested in this
petition for services provided in connection with the claim giving rise to this petition. (If you answered ''has,'' identify the person
who paid the fees or other compensation, the amounts paid, and the dates of payment):
Amounts
DatesFrom whom (names)
Continued on Attachment 18c.
18.
(1)
b.
State Bar number:
Law firm:
Address:
(2)
(3)
(4)
(1)
c.
$
$
$
$
$
do not asserted. Petitioner and the attorney
Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim
do have an agreement for services provided in
connection with the claim giving rise to this petition. (If you answered ''do,'' attach a copy of the agreement as
Attachment 18a, and complete items 18b.–18f.)
does notf. The attorney does expect to receive attorney's fees or other compensation in addition to that
requested in this petition for services provided in connection with the claim giving rise to this petition. (If you answered ''does,''
identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment):
From whom
(names) Amounts Expected dates
Continued on Attachment 18f.
$
$
$
$
$
The attorney
is not is representing or employed by any other party or any insurance carrier involved in the
matter. (If you answered "is," identify the party or carrier and explain the relationship in Attachment 18e.)
e.
The attorney did not did become concerned with this matter, directly or indirectly, at the instance of a party
against whom the claim is asserted or a party's insurance carrier. (If you answered ''did," explain the circumstances in
Attachment 18d.)
d.
Page 8 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
will be deposited in insured accounts in one or more financial
Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or
conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows
(check all that apply):
(a)
(3)
$
institutions in this state from which no withdrawals can be made without a court order.
The name, branch, and address of each depository are specified in Attachment 19a(3).
(b)
withdrawal only on order of the court. The terms and conditions of the annuity are specified in
Attachment 19a(3).
will be transferred to a custodian for the benefit of the minor under the
(c)
will be invested in a single-premium deferred annuity subject to
$
$
California Uniform Transfers to Minors Act. The name and address of the proposed custodian
and the property to be transferred are specified in Attachment 19a(3).
(d) will be transferred to the trustee of a trust that is either created by or
$
approved of in the order approving the settlement or the judgment given or to be given for the
minor. This trust is revocable when the minor attains the age of 18 years and contains all other
terms and conditions determined to be necessary by the court to protect the minor's interests. The
terms of the proposed trust and the property to be transferred are specified in Attachment 19a(3).
A copy of the (proposed) judgment is attached as Attachment 4c.
Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
19.
There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a
a.
disability filed in (name of court):
Case no.:
(1)
the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money
or other property is specified in Attachment 19a(1).
of the proceeds in money or other property will be paid or delivered to $
(2)
Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability.
Petitioner requests authority to deposit or invest $
property to be paid or delivered under 19a(1) with one or more financial institutions in this state or with a trust
company, subject to withdrawal only as authorized by the court. The money or other property and the name,
branch, and address of each financial institution or trust company are specified in Attachment 19a(2).
of the money or other
(e)
will be transferred to the trustee of a special needs trust under
$
Probate Code sections 3602(d) and 3604 for the benefit of the minor or the adult person with a
disability. The terms of the proposed special needs trust and the property to be transferred are
specified in Attachment 19a(3).
Page 9 of 10
MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
19.
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
approved of in the order approving the settlement or the judgment given or to be given for the minor. This
trust is revocable when the minor attains the age of 18 years and contains all other terms and conditions
determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and
the money or other property to be transferred are specified in Attachment 19b(7).
(7)
(9)
will be transferred to the trustee of a trust that is either created by or$
discretion determines is in the best interest of the minor or the adult person with a disability. The proposed
conditions and the property are specified in Attachment 19b(9).
of property other than money will be held on such conditions as the court in its $
A copy of the (proposed) judgment is attached as Attachment 4c.
is in the best interest of the minor or the adult person with a disability. The proposed conditions are specified
on Attachment 19b(8). (Value must not exceed $20,000.)
(8) of money will be held on such conditions as the court in its discretion determines $
(10)
Continued on Attachment 19.
will be paid or transferred to the adult person with a disability. The money or other
will be deposited with the county treasurer of the County of (name):
The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h).
$
$
property is specified in Attachment 19b(11).
(11)
Disposition of balance of proceeds of settlement or judgment (cont.)
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
Probate Code sections 3604 and 3611(c) for the benefit of the minor or the adult person with a disability.
The terms of the proposed special needs trust and the money or other property to be paid or transferred are
specified in Attachment 19b(4).
(4)
conditions specified in Probate Code sections 3401–3402, without bond. The name and address of the
parent and the money or other property to be delivered are specified in Attachment 19b(5). (Value of minor's
entire estate, including the money or property to be delivered, must not exceed $5,000.)
(5)
Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other
property to be transferred are specified in Attachment 19b(6).
(6)
will be transferred to a custodian for the benefit of the minor under the California
$
will be paid or delivered to a parent of the minor, upon the terms and under the
$
will be paid or transferred to the trustee of a special needs trust under
$
b. There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability.
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows
(check all that apply):
(1)
A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability
(2)
institutions in this state, subject to withdrawal only upon the authorization of the court. The name,
branch, and address of each depository are specified in Attachment 19b(2).
$ of money will be deposited in insured accounts in one or more financial
to the person so appointed. The money or other property are specified in Attachment 19b(1).
will be appointed. $ of money and other property will be paid or delivered
(3)
withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified
in Attachment 19b(3).
$
of money will be invested in a single-premium deferred annuity, subject to
Page 10 of 10MC-350 [Rev. January 1, 2011]
CASE NAME:
CASE NUMBER:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
21.
Petitioner requests the following additional orders (specify and explain):
Continued on Attachment 21.
Additional orders
Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to
the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise
settlement or proposed disposition and make such other and further orders as may be just and reasonable.
Number of pages attached:
Date:
(TYPE OR PRINT NAME OF ATTORNEY) (SIGNATURE OF ATTORNEY)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
22.
23.
(TYPE OR PRINT NAME OF PETITIONER)
(SIGNATURE OF PETITIONER)
Statutory liens for special needs trust
20.
Petitioner requests a court order for payment of funds to a special needs trust (explain how statutory liens under Probate
Code section 3604, if any, will be satisfied):
Continued on Attachment 20.
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MC-350 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (The Superior Court of California - County of Orange)

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Completed 9 February 2021

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