ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & Address):
Telephone No.: Fax No. (Optional):
E-Mail Address (Optional):
ATTORNEY FOR (Name): Bar No:
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE
&(175$/JUSTICE CENTER:
700 Civic Center Dr. West, Santa Ana, CA 92701-4045
APPELLANT:
RESPONDENT:
NOTICE OF APPEAL – CIVIL CITATION
CASE NO:
Civil Citation fine/penalty has been paid. has been waived by the citing agency.
Contestant/Appellant, , of the above entitled action,
having exhausted the administrative review process, hereby appeals to the Superior Court of California, County of Orange
from the final decision of the administrative review, which was mailed or personally served on ,
regarding Civil Citation number: .
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF APPELLANT OR ATTORNEY)
NOTE: A separate appeal must be filed for each civil citation. A copy of this document must be mailed to the citing
agency. The original appeal with proof of service must be filed with the court with the proper filing fee.
PROOF OF SERVICE BY MAIL
I deposited a copy of the Notice of Appe al in the United St ates mail, in a sealed envelope with postage fully prepaid. The
envelope was addressed as follows: (Name and address of citing agency)
Date of mailing: Place of mailing (city and state): .
I am a resident of or empl oyed in the county whe re the Notice of Appeal was mailed. My residence or business address
is: Street Address: City: State: .
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
________________________
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
Approved for Optional Use
L-1044 (Rev. July 2013)
NOTICE OF APPEAL - CIVIL CITATION
Govt. Code § 53069.4
www.occourts.org
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