Xaime Casillas v. City of Los Angeles et al

Filing 40

PROTECTIVE ORDER by Magistrate Judge Gail J. Standish. (ec)

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1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 XAIME CASILLAS, 12 v. 13 14 CITY OF LOS ANGELES, et al., 15 Case No. 2:16-cv-09606 TJH (GJSx) DISCOVERY MATTER [PROPOSED] ORDER REGARDING AMENDED STIPULATED PROTECTIVE ORDER1 Defendants. 16 17 Pursuant to Fed. R. Civ. P. 26(c), the parties (each a “Party,” and together, the 18 19 “Parties”) to this litigation, by their counsel of record, stipulate and move the Court 20 for the entry of a Stipulated Protective Order in the above-captioned matter. 21 1. A. PURPOSES AND LIMITATIONS Discovery in this action is likely to involve production of confidential, 22 23 proprietary or private information for which special protection from public 24 disclosure and from use for any purpose other than prosecuting this litigation may 25 be warranted. Accordingly, the parties hereby stipulate to and petition the Court to 26 enter the following Stipulated Protective Order. The parties acknowledge that this 27 28 1 This Stipulated Protective Order is substantially based on the model protective order provided under Magistrate Judge Gail J. Standish’s Procedures. 1 Order does not confer blanket protections on all disclosures or responses to 2 discovery and that the protection it affords from public disclosure and use extends 3 only to the limited information or items that are entitled to confidential treatment 4 under the applicable legal principles. 5 6 B. GOOD CAUSE STATEMENT 7 This action is likely to involve confidential or sensitive information and 8 material and/or proprietary information for which special protection from public 9 disclosure and from use for any purpose other than prosecution of this action is 10 warranted. Without waiving any objections any party may have to the discovery 11 request or documents sought, and without agreeing that such documents will be 12 produced as described in this paragraph, such confidential and proprietary materials 13 and information may consist of, among other things, plaintiff’s medical records, 14 Defendants’ personnel records, investigation reports, complaints, training materials 15 and bulletins, policies, special and general orders, use of force directives, and other 16 information otherwise generally unavailable to the public, or which may be 17 privileged or otherwise protected from disclosure under state or federal statutes, 18 court rules, case decisions, or common law. Accordingly, to expedite the flow of 19 information, to facilitate the prompt resolution of disputes over confidentiality of 20 discovery materials, to adequately protect information the parties are entitled to keep 21 confidential, to ensure that the parties are permitted reasonable necessary uses of 22 such material in preparation for and in the conduct of depositions and trial, to 23 address their handling at the end of the litigation, and serve the ends of justice, a 24 protective order for such information is justified in this matter. 25 It is the intent of the parties that information will not be designated as 26 confidential for tactical reasons and that nothing be so designated without a good 27 faith belief that it has been maintained in a confidential, non-public manner, and 28 there is good cause why it should not be part of the public record of this case. 2 1 C. ACKNOWLEDGMENT OF PROCEDURE FOR FILING UNDER SEAL 2 The parties further acknowledge, as set forth in Section 12.3, below, that this 3 Stipulated Protective Order does not entitle them to file confidential information 4 under seal; Local Civil Rule 79-5 sets forth the procedures that must be followed 5 and the standards that will be applied when a party seeks permission from the court 6 to file material under seal. 7 There is a strong presumption that the public has a right of access to judicial 8 proceedings and records in civil cases. In connection with non-dispositive motions, 9 good cause must be shown to support a filing under seal. See Kamakana v. City and 10 County of Honolulu, 447 F.3d 1172, 1176 (9th Cir. 2006), Phillips v. Gen. Motors 11 Corp., 307 F.3d 1206, 1210-11 (9th Cir. 2002), Makar-Welbon v. Sony Electrics, 12 Inc., 187 F.R.D. 576, 577 (E.D. Wis. 1999) (even stipulated protective orders 13 require good cause showing), and a specific showing of good cause or compelling 14 reasons with proper evidentiary support and legal justification, must be made with 15 respect to Protected Material that a party seeks to file under seal. The parties’ mere 16 designation of Disclosure or Discovery Material as CONFIDENTIAL does not— 17 without the submission of competent evidence by declaration, establishing that the 18 material sought to be filed under seal qualifies as confidential, privileged, or 19 otherwise protectable—constitute good cause. 20 Further, if a party requests sealing related to a dispositive motion or trial, then 21 compelling reasons, not only good cause, for the sealing must be shown, and the 22 relief sought shall be narrowly tailored to serve the specific interest to be protected. 23 See Pintos v. Pacific Creditors Ass’n, 605 F.3d 665, 677-79 (9th Cir. 2010). For 24 each item or type of information, document, or thing sought to be filed or introduced 25 under seal in connection with a dispositive motion or trial, the party seeking 26 protection must articulate compelling reasons, supported by specific facts and legal 27 justification, for the requested sealing order. Again, competent evidence supporting 28 the application to file documents under seal must be provided by declaration. 3 Any document that is not confidential, privileged, or otherwise protectable in 1 2 its entirety will not be filed under seal if the confidential portions can be redacted. 3 If documents can be redacted, then a redacted version for public viewing, omitting 4 only the confidential, privileged, or otherwise protectable portions of the document, 5 shall be filed. Any application that seeks to file documents under seal in their 6 entirety should include an explanation of why redaction is not feasible. 7 8 2. DEFINITIONS 9 2.1 Action: Xaime Casillas v. City of Los Angeles, et al., 2:16-cv-09606. 10 2.2 Challenging Party: a Party or Non-Party that challenges the 11 12 designation of information or items under this Order. 2.3 “CONFIDENTIAL” Information or Items: information (regardless of 13 how it is generated, stored or maintained) or tangible things that qualify for 14 protection under Federal Rule of Civil Procedure 26(c), and as specified above in 15 the Good Cause Statement. 16 17 18 2.4 Counsel: Outside Counsel of Record and House Counsel (as well as their support staff). 2.5 Designating Party: a Party or Non-Party that designates information or 19 items that it produces in disclosures or in responses to discovery as 20 “CONFIDENTIAL.” 21 2.6 Disclosure or Discovery Material: all items or information, regardless 22 of the medium or manner in which it is generated, stored, or maintained (including, 23 among other things, testimony, transcripts, and tangible things), that are produced or 24 generated in disclosures or responses to discovery in this matter. 25 2.7 Expert: a person with specialized knowledge or experience in a matter 26 pertinent to the litigation who has been retained by a Party or its counsel to serve as 27 an expert witness or as a consultant in this Action. 28 2.8 House Counsel: attorneys who are employees of a party to this Action. 4 1 House Counsel does not include Outside Counsel of Record or any other outside 2 counsel. 2.9 3 4 Non-Party: any natural person, partnership, corporation, association or other legal entity not named as a Party to this action. 2.10 Outside Counsel of Record: attorneys who are not employees of a 5 6 party to this Action but are retained to represent or advise a party to this Action and 7 have appeared in this Action on behalf of that party or are affiliated with a law firm 8 that has appeared on behalf of that party, and includes support staff. 2.11 Party: any party to this Action, including all of its officers, directors, 9 10 employees, consultants, retained experts, and Outside Counsel of Record (and their 11 support staffs). 2.12 Producing Party: a Party or Non-Party that produces Disclosure or 12 13 Discovery Material in this Action. 14 2.13 Professional Vendors: persons or entities that provide litigation 15 support services (e.g., photocopying, videotaping, translating, preparing exhibits or 16 demonstrations, and organizing, storing, or retrieving data in any form or medium) 17 and their employees and subcontractors. 2.14 Protected Material: any Disclosure or Discovery Material that is 18 19 designated as “CONFIDENTIAL.” 2.15 Receiving Party: a Party that receives Disclosure or Discovery 20 21 Material from a Producing Party. 22 23 3. SCOPE 24 The protections conferred by this Stipulation and Order cover not only 25 Protected Material (as defined above), but also (1) any information copied or 26 extracted from Protected Material; (2) all copies, excerpts, summaries, or 27 compilations of Protected Material; and (3) any testimony, conversations, or 28 presentations by Parties or their Counsel that might reveal Protected Material. 5 Any use of Protected Material at trial shall be governed by the orders of the 1 2 trial judge. This Order does not govern the use of Protected Material at trial. 3 4 4. DURATION Once a case proceeds to trial, information that was designated as 5 6 CONFIDENTIAL or maintained pursuant to this protective order used or introduced 7 as an exhibit at trial becomes public and will be presumptively available to all 8 members of the public, including the press, unless compelling reasons supported by 9 specific factual findings to proceed otherwise are made to the trial judge in advance 10 of the trial. See Kamakana, 447 F.3d at 1180-81 (distinguishing “good cause” 11 showing for sealing documents produced in discovery from “compelling reasons” 12 standard when merits-related documents are part of court record). Accordingly, the 13 terms of this protective order do not extend beyond the commencement of the trial. 14 15 16 5. DESIGNATING PROTECTED MATERIAL 5.1 Exercise of Restraint and Care in Designating Material for Protection. 17 Each Party or Non-Party that designates information or items for protection under 18 this Order must take care to limit any such designation to specific material that 19 qualifies under the appropriate standards. The Designating Party must designate for 20 protection only those parts of material, documents, items or oral or written 21 communications that qualify so that other portions of the material, documents, items 22 or communications for which protection is not warranted are not swept unjustifiably 23 within the ambit of this Order. 24 Mass, indiscriminate or routinized designations are prohibited. Designations 25 that are shown to be clearly unjustified or that have been made for an improper 26 purpose (e.g., to unnecessarily encumber the case development process or to impose 27 unnecessary expenses and burdens on other parties) may expose the Designating 28 Party to sanctions. 6 1 If it comes to a Designating Party’s attention that information or items that it 2 designated for protection do not qualify for protection, that Designating Party must 3 promptly notify all other Parties that it is withdrawing the inapplicable designation. 4 5.2 Manner and Timing of Designations. Except as otherwise provided in 5 this Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise 6 stipulated or ordered, Disclosure or Discovery Material that qualifies for protection 7 under this Order must be clearly so designated before the material is disclosed or 8 produced. 9 Designation in conformity with this Order requires: 10 (a) for information in documentary form (e.g., paper or electronic 11 documents, but excluding transcripts of depositions or other pretrial or trial 12 proceedings), that the Producing Party affix at a minimum, the legend 13 “CONFIDENTIAL” (hereinafter “CONFIDENTIAL legend”), to each page that 14 contains protected material. If only a portion of the material on a page qualifies for 15 protection, the Producing Party also must clearly identify the protected portion(s) 16 (e.g., by making appropriate markings in the margins). 17 A Party or Non-Party that makes original documents available for inspection 18 need not designate them for protection until after the inspecting Party has indicated 19 which documents it would like copied and produced. During the inspection and 20 before the designation, all of the material made available for inspection shall be 21 deemed “CONFIDENTIAL.” After the inspecting Party has identified the 22 documents it wants copied and produced, the Producing Party must determine which 23 documents, or portions thereof, qualify for protection under this Order. Then, 24 before producing the specified documents, the Producing Party must affix the 25 “CONFIDENTIAL legend” to each page that contains Protected Material. If only a 26 portion of the material on a page qualifies for protection, the Producing Party also 27 must clearly identify the protected portion(s) (e.g., by making appropriate markings 28 in the margins). 7 (b) for testimony given in depositions that the Designating Party identifies 1 2 the Disclosure or Discovery Material on the record, before the close of the 3 deposition all protected testimony. (c) for information produced in some form other than documentary and 4 5 for any other tangible items, that the Producing Party affix in a prominent place on 6 the exterior of the container or containers in which the information is stored the 7 legend “CONFIDENTIAL.” If only a portion or portions of the information 8 warrants protection, the Producing Party, to the extent practicable, shall identify the 9 protected portion(s). 5.3 10 Inadvertent Failures to Designate. If timely corrected, an inadvertent 11 failure to designate qualified information or items does not, standing alone, waive 12 the Designating Party’s right to secure protection under this Order for such material. 13 Upon timely correction of a designation, the Receiving Party must make reasonable 14 efforts to assure that the material is treated in accordance with the provisions of this 15 Order. 16 17 18 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS 6.1 Timing of Challenges. Any Party or Non-Party may challenge a 19 designation of confidentiality at any time that is consistent with the Court’s 20 Scheduling Order. 21 22 23 6.2 Meet and Confer. The Challenging Party shall initiate the dispute resolution process under Local Rule 37.1 et seq. 6.3 The burden of persuasion in any such challenge proceeding shall be on 24 the Designating Party. Frivolous challenges, and those made for an improper 25 purpose (e.g., to harass or impose unnecessary expenses and burdens on other 26 parties) may expose the Challenging Party to sanctions. Unless the Designating 27 Party has waived or withdrawn the confidentiality designation, all parties shall 28 continue to afford the material in question the level of protection to which it is 8 1 entitled under the Producing Party’s designation until the Court rules on the 2 challenge. 3 4 5 7. ACCESS TO AND USE OF PROTECTED MATERIAL 7.1 Basic Principles. A Receiving Party may use Protected Material that is 6 disclosed or produced by another Party or by a Non-Party in connection with this 7 Action only for prosecuting, defending or attempting to settle this Action. Such 8 Protected Material may be disclosed only to the categories of persons and under the 9 conditions described in this Order. When the Action has been terminated, a 10 Receiving Party must comply with the provisions of section 13 below (FINAL 11 DISPOSITION). 12 Protected Material must be stored and maintained by a Receiving Party at a 13 location and in a secure manner that ensures that access is limited to the persons 14 authorized under this Order. 15 7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless 16 otherwise ordered by the court or permitted in writing by the Designating Party, a 17 Receiving Party may disclose any information or item designated 18 “CONFIDENTIAL” only to: 19 (a) the Receiving Party’s Outside Counsel of Record in this Action, as 20 well as employees of said Outside Counsel of Record to whom it is reasonably 21 necessary to disclose the information for this Action; 22 (b) the officers, directors, and employees (including House Counsel) of 23 the Receiving Party to whom disclosure is reasonably necessary for this Action; 24 (c) Experts (as defined in this Order) of the Receiving Party to whom 25 disclosure is reasonably necessary for this Action and who have signed the 26 “Acknowledgment and Agreement to Be Bound” (Exhibit A); 27 (d) the court and its personnel; 28 (e) court reporters and their staff; 9 (f) professional jury or trial consultants, mock jurors, and Professional 1 2 Vendors to whom disclosure is reasonably necessary for this Action and who have 3 signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A); (g) the author or recipient of a document containing the information or a 4 5 custodian or other person who otherwise possessed or knew the information; 6 (h) during their depositions, witnesses, and attorneys for witnesses, in the 7 Action to whom disclosure is reasonably necessary provided: (1) the deposing party 8 requests that the witness sign the form attached as Exhibit 1 hereto; and (2) they will 9 not be permitted to keep any confidential information unless they sign the 10 “Acknowledgment and Agreement to Be Bound” (Exhibit A), unless otherwise 11 agreed by the Designating Party or ordered by the court. Pages of transcribed 12 deposition testimony or exhibits to depositions that reveal Protected Material may 13 be separately bound by the court reporter and may not be disclosed to anyone except 14 as permitted under this Stipulated Protective Order; and (i) any mediator or settlement officer, and their supporting personnel, 15 16 mutually agreed upon by any of the parties engaged in settlement discussions. 17 18 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED 19 IN OTHER LITIGATION 20 If a Party is served with a subpoena or a court order issued in other litigation 21 that compels disclosure of any information or items designated in this Action as 22 “CONFIDENTIAL,” that Party must: 23 24 25 (a) promptly notify in writing the Designating Party. Such notification shall include a copy of the subpoena or court order; (b) promptly notify in writing the party who caused the subpoena or order 26 to issue in the other litigation that some or all of the material covered by the 27 subpoena or order is subject to this Protective Order. Such notification shall include 28 a copy of this Stipulated Protective Order; and 10 (c) cooperate with respect to all reasonable procedures sought to be 1 2 pursued by the Designating Party whose Protected Material may be affected. If the Designating Party timely seeks a protective order, the Party served with 3 4 the subpoena or court order shall not produce any information designated in this 5 action as “CONFIDENTIAL” before a determination by the court from which the 6 subpoena or order issued, unless the Party has obtained the Designating Party’s 7 permission. The Designating Party shall bear the burden and expense of seeking 8 protection in that court of its confidential material and nothing in these provisions 9 should be construed as authorizing or encouraging a Receiving Party in this Action 10 to disobey a lawful directive from another court. 11 12 13 14 9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE PRODUCED IN THIS LITIGATION (a) The terms of this Order are applicable to information produced by a 15 Non-Party in this Action and designated as “CONFIDENTIAL.” Such information 16 produced by Non-Parties in connection with this litigation is protected by the 17 remedies and relief provided by this Order. Nothing in these provisions should be 18 construed as prohibiting a Non-Party from seeking additional protections. 19 (b) In the event that a Party is required, by a valid discovery request, to 20 produce a Non-Party’s confidential information in its possession, and the Party is 21 subject to an agreement with the Non-Party not to produce the Non-Party’s 22 confidential information, then the Party shall: 23 (1) promptly notify in writing the Requesting Party and the Non-Party 24 that some or all of the information requested is subject to a confidentiality 25 agreement with a Non-Party; 26 (2) promptly provide the Non-Party with a copy of the Stipulated 27 Protective Order in this Action, the relevant discovery request(s), and a reasonably 28 specific description of the information requested; and 11 (3) make the information requested available for inspection by the 1 2 Non-Party, if requested. 3 (c) If the Non-Party fails to seek a protective order from this court within 4 14 days of receiving the notice and accompanying information, the Receiving Party 5 may produce the Non-Party’s confidential information responsive to the discovery 6 request. If the Non-Party timely seeks a protective order, the Receiving Party shall 7 not produce any information in its possession or control that is subject to the 8 confidentiality agreement with the Non-Party before a determination by the court. 9 Absent a court order to the contrary, the Non-Party shall bear the burden and 10 expense of seeking protection in this court of its Protected Material. 11 12 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 13 14 Protected Material to any person or in any circumstance not authorized under this 15 Stipulated Protective Order, the Receiving Party must immediately (a) notify in 16 writing the Designating Party of the unauthorized disclosures, (b) use its best efforts 17 to retrieve all unauthorized copies of the Protected Material, (c) inform the person or 18 persons to whom unauthorized disclosures were made of all the terms of this Order, 19 and (d) request such person or persons to execute the “Acknowledgment and 20 Agreement to Be Bound” that is attached hereto as Exhibit A. 21 22 11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 23 PROTECTED MATERIAL 24 When a Producing Party gives notice to Receiving Parties that certain 25 inadvertently produced material is subject to a claim of privilege or other protection, 26 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil 27 Procedure 26(b)(5)(B). This provision is not intended to modify whatever 28 procedure may be established in an e-discovery order that provides for production 12 1 without prior privilege review. Pursuant to Federal Rule of Evidence 502(d) and 2 (e), insofar as the parties reach an agreement on the effect of disclosure of a 3 communication or information covered by the attorney-client privilege or work 4 product protection, the parties may incorporate their agreement in the stipulated 5 protective order submitted to the court. 6 7 12. 12.1 Right to Further Relief. Nothing in this Order abridges the right of any 8 9 MISCELLANEOUS person to seek its modification by the Court in the future. 12.2 Right to Assert Other Objections. By stipulating to the entry of this 10 11 Protective Order, no Party waives any right it otherwise would have to object to 12 disclosing or producing any information or item on any ground not addressed in this 13 Stipulated Protective Order. Similarly, no Party waives any right to object on any 14 ground to use in evidence of any of the material covered by this Protective Order. 15 12.3 Filing Protected Material. A Party that seeks to file under seal any 16 Protected Material must comply with Local Civil Rule 79-5. Protected Material 17 may only be filed under seal pursuant to a court order authorizing the sealing of the 18 specific Protected Material at issue. If a Party’s request to file Protected Material 19 under seal is denied by the court, then the Receiving Party may file the information 20 in the public record unless otherwise instructed by the court. 21 22 23 13. FINAL DISPOSITION After the final disposition of this Action, as defined in paragraph 4, within 60 24 days of a written request by the Designating Party, each Receiving Party must return 25 all Protected Material to the Producing Party or destroy such material. As used in 26 this subdivision, “all Protected Material” includes all copies, abstracts, compilations, 27 summaries, and any other format reproducing or capturing any of the Protected 28 Material. Whether the Protected Material is returned or destroyed, the Receiving 13 1 Party must submit a written certification to the Producing Party (and, if not the same 2 person or entity, to the Designating Party) by the 60 day deadline that (1) identifies 3 (by category, where appropriate) all the Protected Material that was returned or 4 destroyed and (2) affirms that the Receiving Party has not retained any copies, 5 abstracts, compilations, summaries or any other format reproducing or capturing any 6 of the Protected Material. Notwithstanding this provision, Counsel are entitled to 7 retain an archival copy of all pleadings, motion papers, trial, deposition, and hearing 8 transcripts, legal memoranda, correspondence, deposition and trial exhibits, expert 9 reports, attorney work product, and consultant and expert work product, even if such 10 materials contain Protected Material. Any such archival copies that contain or 11 constitute Protected Material remain subject to this Protective Order as set forth in 12 Section 4 (DURATION). 13 /// 14 /// 15 /// 16 /// 17 /// 18 /// 19 /// 20 /// 21 /// 22 /// 23 /// 24 /// 25 /// 26 /// 27 /// 28 /// 14 1 14. VIOLATION 2 Any violation of this Order may be punished by appropriate measures including, 3 without limitation, contempt proceedings and/or monetary sanctions. 4 IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD. 5 6 DATED: 6/07/18 SCHONBRUN SEPLOW HARRIS & HOFFMAN, LLP 7 8 HAYSBERT MOULTRIE, LLP 9 11 By: /s/ Nazareth M. Haysbert Nazareth M. Haysbert, Esq. James Moultrie, III, Esq. 12 Attorneys for Plaintiff XAIME CASILLAS 10 13 14 DATED: 6/07/18 15 MICHAEL N. FEUER, City Attorney THOMAS H. PETERS, Chief Asst. City Atty. CORY M. BRENTE, Supervising Asst. City Atty. 16 By: /s/ Surekha A. Shepherd Surekha A. Shepherd, Deputy City Attorney Attorneys for Defendants CITY OF LOS ANGELES, OFFICER ROBERT LOCKHART, OFFICER ROBERT COSNER, OFFICER THOMAS TAVARES, OFFICER CECILIO FLORES, and CAPTAIN ART SANDOVAL 17 18 19 20 21 22 23 FOR GOOD CAUSE SHOWN, IT IS SO ORDERED. 24 25 DATED: June 11, 2018 26 27 28 _____________________________________ GAIL J. STANDISH UNITED STATES MAGISTRATE JUDGE 15 1 EXHIBIT A 2 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND 3 4 I, _____________________________ [print or type full name], of 5 _________________ [print or type full address], declare under penalty of perjury 6 that I have read in its entirety and understand the Stipulated Protective Order that 7 was issued by the United States District Court for the Central District of California 8 on [date] in the case of ___________ Xaime Casillas v. City of Los Angeles, et al., 9 2:16-cv-09606 TJH (GJSx). I agree to comply with and to be bound by all the 10 terms of this Stipulated Protective Order and I understand and acknowledge that 11 failure to so comply could expose me to sanctions and punishment in the nature of 12 contempt. I solemnly promise that I will not disclose in any manner any 13 information or item that is subject to this Stipulated Protective Order to any person 14 or entity except in strict compliance with the provisions of this Order. 15 I further agree to submit to the jurisdiction of the United States District Court for the 16 Central District of California for enforcing the terms of this Stipulated Protective 17 Order, even if such enforcement proceedings occur after termination of this action. 18 I hereby appoint __________________________ [print or type full name] of 19 _______________________________________ [print or type full address and 20 telephone number] as my California agent for service of process in connection with 21 this action or any proceedings related to enforcement of this Stipulated Protective 22 Order. 23 Date: ______________________________________ 24 City and State where sworn and signed: _________________________________ 25 26 Printed name: _______________________________ 27 28 Signature: __________________________________ 16

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