Civil Case Cover Sheet Addendum And Statement Page 4
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1
2
3
4SHORT TITLE:
CASE NUMBER
Sheriff
Thomas
Bosenko, et al. v. The
City
of Los Angeles, et a!.
REASON: Check the appropriate boxes for the numbers shown
under Column C for the type of action that you have selected for
this case.
1.[i2.[3.LJ4.i5.[
6
X 7
X
9
Q
Item
IV.
Declaration of Assignment:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct and that the above-entitled matter is properly filed for assignment to the
Stanley Mosk
courthouse in the
of the Superior Court of California, County of Los Angeles [Code Civ. Proc.,
§
392 et seq., and Local
Rule 2.3, subd.(a).
Dated:
10
2Si
PLEASE HAVE THE FOLLOWING ITEMS COMPLETED AND READY TO BE FILED IN ORDER TO PROPERLY
COMMENCE YOUR NEW COURT CASE:
1.
Original Complaint or Petition.
2.
If filing a Complaint, a completed Summons form for issuance by the Clerk.
3.
Civil Case Cover Sheet, Judicial Council form CM-01O.
4.
Civil Case Cover Sheet Addendum and Statement of Location form, LACIV 109, LASC Approved 03-04 (Rev.
03/15).
5.
Payment in full of the filing fee, unless fees have been waived.
6. A signed order appointing the Guardian ad Litem, Judicial Council form CIV-01 0, if the plaintiff or petitioner is a
minor under 18 years of age will be required by Court in order to issue a summons.
7.
Additional copies of documents to be conformed by the Clerk. Copies of the cover sheet and this addendum
must be served along with the summons and complaint, or other initiating pleading in the case.
LACIV 109 (Rev 3/15)
LASC Approved 03-04
CIVIL CASE COVER SHEET ADDENDUM
AND STATEMENT OF LOCATION
Local Rule 2.3
Page 4
of 4
Item III. Statement of Location: Enter the address of the accident, party’s residence or place of business, performance, or other
circumstance indicated in Item II., Step
3
on Page 1, as the proper reason for filing in the court location you selected.
ADDRESS:
200 N.
Spring Street
CITY:
Los Angeles
STATE:
CA
ZIP CODE:
90012
(SIGNATURE OF ATTORNEY/FILING PARTY)
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