Fillable SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE Central (The Superior Court of California - County of Orange)

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

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ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NO.:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE NO.:
FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE
JUSTICE CENTER:
Central - 700 Civic Center Dr. West, Santa Ana, CA 92701-4045
Harbor - Newport Beach Facility-4601 Jamboree Rd., Newport Beach, CA 92660-2595
North - 1275 N. Berkeley Ave., P. O. Box 5000, Fullerton, CA 92838-0500
West - 8141 13
th
Street, Westminster, CA 92683-4593
PETITIONER:
RESPONDENT:
DECLARATION OF DEFAULT/NON-COMPLIANCE
Civil Harassment
Workplace Violence
Elder or Dependent Adult Abuse
Private Postsecondary School Violence
CASE NUMBER:
I am the petitioner/respondent in this case, and on (date): the above mentioned parties
filed a stipulation in this case.
Parties agreed to the terms of the stipulation, but the other party failed to comply with the stipulation as follows:
Attached is a completed Order to Show Cause or Notice of Court Hearing form (CH-109, WV-109, SV-109, or
EA-109), and I request a hearing within 21 days. I understand that I must have the new Notice of Hearing or
Order to Show Cause personally served on the respondent.
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 Form
#L-0839 (Rev. March. 2019)
DECLARATION OF DEFAULT/NON-COMPLIANCE
CIVIL HARASSMENT/WORKPLACE VIOLENCE/ ELDER OR
DEPENDENT ADULT ABUSE/PRIVATE POST-SECONDARY
SCHOOL VIOLENCE
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE Central (The Superior Court of California - County of Orange)

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Completed 8 February 2021

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