Graham et al v. Vassar College
Filing
67
STIPULATED PROTECTIVE ORDER...regarding procedures to be followed that shall govern the handling of confidential material... (Signed by Magistrate Judge Victoria Reznik on 1/29/2025) (rro)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK
WENDY GRAHAM, MARIA HÖHN, MIA
MASK, CINDY SCHWARZ, and DEBRA
ZEIFMAN on behalf of themselves and all others
similarly situated,
No. 7:23-cv-07692
STIPULATED
PROTECTIVE ORDER
Plaintiffs,
v.
VASSAR COLLEGE,
Defendant.
IT IS HEREBY STIPULATED AND AGREED by and between counsel for Plaintiffs
and Defendant that the terms of this Stipulated Protective Order (“Order”) shall govern and apply
to all documents, information contained in documents, and all other information or things
produced or disclosed in connection with this action, whether produced by a party or non-party,
and whether produced in a document, a discovery response, deposition or other testimony, or
otherwise.
I.
PURPOSES AND LIMITATIONS
Disclosure and discovery activity in this action are likely to involve production of
confidential, proprietary, or private information for which special protection from public
disclosure and from use for any purpose other than prosecuting this litigation may be warranted.
Accordingly, the parties hereby stipulate to and petition the court to enter the following
Stipulated Protective Order. The parties acknowledge that this Order does not confer blanket
protections on all disclosures or responses to discovery and that the protection it affords from
public disclosure and use extends only to the limited information or items that are entitled to
confidential treatment under the applicable legal principles. The parties further acknowledge that
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this Stipulated Protective Order does not entitle them to file confidential information under seal.
II.
DEFINITIONS
2.1
Challenging Party: a Party or Non-Party that challenges the designation of
information or items under this Order.
2.2
“CONFIDENTIAL” Information or Items: information (regardless of how it is
generated, stored or maintained) or tangible things that qualify for protection under Federal Rule
of Civil Procedure 26(c), including but not limited to materials reflecting sensitive personal
identifying information, such as Social Security Numbers, phone numbers, employment
histories, credit card information, and/or materials reflecting a Party’s non-public financial
information. Subject to potential challenge as set forth in section 6 below (CHALLENGING
CONFIDENTIALITY DESIGNATIONS), Confidential Information may also include, but is not
limited to, the following documents and tangible things produced or otherwise exchanged where
all such information is not readily ascertainable and the Party asserting confidentiality has taken
reasonable steps to maintain its confidentiality:
2.3
?
Competitively sensitive technical, marketing, financial, sales, or other
confidential business information;
?
Private confidential personal information, including personnel and
compensation data and other sensitive information related to the litigants;
?
Information received in confidence from third parties;
?
Non-public income statements or balance sheets;
?
Statistical data reported to government agencies that is not otherwise publicly
available;
?
Non-public accounting information or tax records; and
?
Document preservation and destruction policies.
Counsel (without qualifier): Outside Counsel of Record and House Counsel (as
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well as their support staff).
2.4
Designating Party: a Party or Non-Party that designates information or items that
it produces in disclosures or in responses to discovery as “CONFIDENTIAL” or “HIGHLY
CONFIDENTIAL – ATTORNEYS’ EYES ONLY”.
2.5
Disclosure or Discovery Material: all items or information, regardless of the
medium or manner in which it is generated, stored, or maintained (including, among other things,
testimony, transcripts, and tangible things), that are produced or generated in disclosures or
responses to discovery in this matter.
2.6
Expert: a person with specialized knowledge or experience in a matter pertinent to
the litigation who (1) has been retained by a Party or its counsel to serve as an expert witness or
as a consultant in this action, (2) is not a past or current employee of a Party or of a Party’s
competitor, and (3) at the time of retention, is not anticipated to become an employee of a Party
or of a Party’s competitor.
2.7
“HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY” Information or
Items: extremely sensitive “Confidential Information or Items,” disclosure of which to another
Party or Non-Party would create a substantial risk of serious harm that could not be avoided by
less restrictive means. Subject to potential challenge as set forth in section 6 below
(CHALLENGING CONFIDENTIALITY DESIGNATIONS), Highly Confidential – Attorneys’
Eyes Only material may include, but is not limited to, the following documents and tangible
things produced or otherwise exchanged:
2.8
?
Trade secrets protected by law; and
?
Personnel and compensation data and other sensitive information pertaining to
third-party non-litigants.
House Counsel: attorneys who are employees of a party to this action. House
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Counsel does not include Outside Counsel of Record or any other outside counsel.
2.9
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 party to this
action but are retained to represent or advise a party to this action and have appeared in this
action on behalf of that party or are affiliated with a law firm which has appeared on behalf of
that party.
2.11
Party: any party to this action.
2.12
Producing Party: a Party or Non-Party that produces Disclosure or Discovery
Material in this action.
2.13
Professional Vendors: persons or entities that have been retained by any Party or
Non-Party to provide litigation support services (e.g., photocopying, videotaping, translating,
preparing exhibits or demonstrations, and organizing, storing, or retrieving data in any form or
medium) in this litigation.
2.14
Protected Material: any Disclosure or Discovery Material that is designated as
“CONFIDENTIAL,” or as “HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY.”
2.15
Receiving Party: a Party that receives Disclosure or Discovery Material from a
Producing Party.
III.
SCOPE
The protections conferred by this Stipulation and Order cover not only Protected Material
(as defined above), but also (1) any information copied or extracted from Protected Material; (2)
all copies, excerpts, summaries, or compilations of Protected Material; and (3) any testimony,
conversations, or presentations by Parties or their Counsel that might reveal Protected Material.
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However, the protections conferred by this Stipulation and Order do not cover the following
information: (a) any information that is in the public domain at the time of disclosure to a
Receiving Party or becomes part of the public domain after its disclosure to a Receiving Party as
a result of publication not involving a violation of this Order, including becoming part of the
public record through trial or otherwise; and (b) any information known to the Receiving Party
prior to the disclosure or obtained by the Receiving Party after the disclosure from a source who
obtained the information lawfully and under no obligation of confidentiality to the Designating
Party. This Stipulation and Order establishes a procedure for expeditious handling of
Confidential or Highly Confidential information; it shall not be construed as an agreement or as
creating any presumption on the confidentiality of any document.
IV.
DURATION
Even after final disposition of this litigation, the confidentiality obligations imposed by
this Order shall remain in effect until a Designating Party agrees otherwise in writing or a court
order otherwise directs. Final disposition shall be deemed to be the later of (1) dismissal of all
claims and defenses in this action, with or without prejudice; and (2) final judgment herein after
the completion and exhaustion of all appeals, rehearings, remands, trials, or reviews of this
action, including the time limits for filing any motions or applications for extension of time
pursuant to applicable law.
V.
DESIGNATING PROTECTED MATERIAL
5.1
Exercise of Restraint and Care in Designating Material for Protection. Each Party
or Non-Party that designates information or items for protection under this Order must take care
to limit any such designation to specific material that qualifies under the appropriate standards.
To the extent it is practical to do so, the Designating Party must designate for protection only
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those parts of material, documents, items, or oral or written communications that qualify – so
that other portions of the material, documents, items, or communications for which protection is
not warranted are not swept unjustifiably within the ambit of this Order.
Designations that are shown to be clearly unjustified or that have been made for an
improper purpose (e.g., to unnecessarily encumber or retard the case development process or to
impose unnecessary expenses and burdens on other parties) are prohibited.
If it comes to a Designating Party’s attention that information or items that it designated
for protection do not qualify for protection at all or do not qualify for the level of protection
initially asserted, that Designating Party must promptly notify all other parties that it is
withdrawing the mistaken designation.
5.2
Manner and Timing of Designations. Except as otherwise provided in this Order,
or as otherwise stipulated or ordered, Disclosure or Discovery Material that qualifies for
protection under this Order must be clearly so designated before the material is disclosed or
produced.
Designation in conformity with this Order requires:
(a) for information in documentary form (e.g., paper or electronic documents, but
excluding transcripts of depositions or other pretrial or trial proceedings), that the Producing
Party affix the legend “CONFIDENTIAL” or “HIGHLY CONFIDENTIAL – ATTORNEYS’
EYES ONLY” to each page that contains protected material. If only a portion or portions of the
material on a page qualifies for protection, the Producing Party also must clearly identify the
protected portion(s) (e.g., by making appropriate markings in the margins) and must specify, for
each portion, the level of protection being asserted.
(b) for testimony given in deposition or in other pretrial or trial proceedings, that the
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Designating Party identify on the record, before the close of the deposition, hearing, or other
proceeding, all protected testimony and specify the level of protection being asserted. A
Designating Party may also, within 30 days after receiving a deposition transcript, designate
portions of the transcript, or exhibits thereto, as “CONFIDENTIAL” or “HIGHLY
CONFIDENTIAL – ATTORNEYS’ EYES ONLY.” Alternatively, when it is impractical to
identify separately each portion of testimony that is entitled to protection and it appears that
substantial portions of the testimony may qualify for protection, a Designating Party may
specify, at the deposition or up to 30 days after receiving the transcript, that the entire transcript
shall be treated as “CONFIDENTIAL” or “HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES
ONLY.”
Parties shall give the other parties notice if they reasonably expect a deposition, hearing
or other proceeding to include Protected Material so that the other parties can ensure that only
authorized individuals who have signed the “Acknowledgment and Agreement to Be Bound”
(Exhibit A) are present at those proceedings. The use of a document as an exhibit at a deposition
shall not in any way affect its designation as “CONFIDENTIAL” or “HIGHLY
CONFIDENTIAL – ATTORNEYS’ EYES ONLY.”
Transcripts containing Protected Material shall have an obvious legend on the title page
that the transcript contains Protected Material, and the title page shall be followed by a list of all
pages (including line numbers as appropriate) that have been designated as Protected Material
and the level of protection being asserted by the Designating Party. The Designating Party shall
inform the court reporter of these requirements. Before the expiration of a 30-day period for
designation, any transcript shall be treated during that period as if it had been designated
“HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY” in its entirety unless otherwise
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agreed, except the Designating Party may provide a copy of the transcript to the deponent within
that period for his or her review. After the expiration of that period, the transcript shall be treated
only as actually designated.
(c) for information produced in some form other than documentary and for any other
tangible items, that the Producing Party affix in a prominent place on the exterior of the
container or containers in which the information or item is stored the legend “CONFIDENTIAL”
or “HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY.” If only a portion or portions
of the information or item warrant protection, the Producing Party, to the extent practicable, shall
identify the protected portion(s) and specify the level of protection being asserted.
5.3
Inadvertent Failures to Designate. If timely corrected, an inadvertent failure to
designate qualified information or items does not, standing alone, waive the Designating Party’s
right to secure protection under this Order for such material. Upon timely correction of a
designation, the Receiving Party must make reasonable efforts to assure that the material is
treated in accordance with the provisions of this Order.
VI.
CHALLENGING CONFIDENTIALITY DESIGNATIONS
6.1
Timing of Challenges. Any Party or Non-Party may challenge a designation of
confidentiality at any time. Unless a prompt challenge to a Designating Party’s confidentiality
designation is necessary to avoid foreseeable, substantial unfairness, unnecessary economic
burdens, or a significant disruption or delay of the litigation, a Party does not waive its right to
challenge a confidentiality designation by electing not to mount a challenge promptly after the
original designation is disclosed.
6.2
Meet and Confer. The Challenging Party shall initiate the dispute resolution
process by providing written notice of each designation it is challenging and describing the basis
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for each challenge. To avoid ambiguity as to whether a challenge has been made, the written
notice must recite that the challenge to confidentiality is being made in accordance with this
specific paragraph of the Protective Order. The parties shall attempt to resolve each challenge in
good faith and must begin the process by conferring directly (in voice to voice dialogue; other
forms of communication are not sufficient) within 14 days of the date of service of notice. In
conferring, the Challenging Party must explain the basis for its belief that the confidentiality
designation was not proper and must give the Designating Party an opportunity to review the
designated material, to reconsider the circumstances, and, if no change in designation is offered,
to explain the basis for the chosen designation. A Challenging Party may proceed to the next
stage of the challenge process only if it has engaged in this meet and confer process first or
establishes that the Designating Party is unwilling to participate in the meet and confer process
within the 14-day window set forth above.
6.3
Judicial Intervention. If the Parties cannot resolve a challenge through the meet
and confer process, the Challenging Party shall seek resolution by the Court in compliance with
the procedures set forth in Judge Victoria Reznik’s Individual Practices in Civil Cases
concerning discovery disputes.
The burden of persuasion in any such challenge proceeding shall be on the Designating
Party. Frivolous challenges and those made for an improper purpose (e.g., to harass or impose
unnecessary expenses and burdens on other parties) are prohibited. All parties shall continue to
afford the material in question the level of protection to which it is entitled under the Producing
Party’s designation until the court rules on the challenge.
VII.
ACCESS TO AND USE OF PROTECTED MATERIAL
7.1
Basic Principles. A Receiving Party may use Protected Material that is disclosed
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or produced by another Party or by a Non-Party in connection with this case only for
prosecuting, defending, or attempting to settle this litigation. Such Protected Material may be
disclosed only to the categories of persons and under the conditions described in this Order.
When the litigation has been terminated, a Receiving Party must comply with the provisions of
section 13 below (FINAL DISPOSITION).
Protected Material must be stored and maintained by a Receiving Party at a location and
in a secure manner that ensures that access is limited to the persons authorized under this Order.
7.2
Disclosure of “CONFIDENTIAL” Information or Items. Unless otherwise
ordered by the court or permitted in writing by the Designating Party, a Receiving Party may
disclose any information or item designated “CONFIDENTIAL” only to:
(a) the Parties;
(b) Counsel, as well as employees of said Counsel to whom it is reasonably necessary to
disclose the information;
(c) the officers, directors, and employees of the Receiving Party to whom disclosure is
reasonably necessary for this litigation and who have signed the “Acknowledgment and
Agreement to Be Bound” (Exhibit A);
(d) Experts to whom disclosure is reasonably necessary for this litigation and who have
signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A);
(e) the court and its personnel;
(f) court reporters and their staff;
(g) professional jury or trial consultants, and Professional Vendors to whom disclosure is
reasonably necessary for this litigation and who have signed the “Acknowledgment and
Agreement to Be Bound” (Exhibit A);
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(g) during their depositions, witnesses in the action to whom disclosure is reasonably
necessary and who have signed the “Acknowledgment and Agreement to Be Bound” (Exhibit
A), unless otherwise agreed by the Designating Party or ordered by the court; and
(h) the author or recipient of a document containing the information or a custodian or
other person who otherwise possessed or knew the information.
7.3
Disclosure of “HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY”
Information or Items. Unless otherwise ordered by the court or permitted in writing by the
Designating Party, a Receiving Party may disclose any information or item designated
“HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY” only to:
(a) the Receiving Party’s Outside Counsel of Record in this action, as well as employees
of said Outside Counsel of Record to whom it is reasonably necessary to disclose the information
for this litigation (such as paralegal and clerical personnel who are actively assisting Outside
Counsel of Record with this litigation), and House Counsel (as well as House Counsel’s
Administrative Assistant) who are engaged in the prosecution or defense of this action;
(b) Experts to whom disclosure is reasonably necessary for this litigation and who have
signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A);
(c) the court and its personnel;
(d) court reporters and their staff;
(e) professional jury or trial consultants, and Professional Vendors to whom disclosure is
reasonably necessary for this litigation and who have signed the “Acknowledgment and
Agreement to Be Bound” (Exhibit A); and
(f) the author or recipient of a document containing the information or a custodian or
other person who otherwise possessed or knew the information.
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Nothing in this Protective Order shall be deemed to restrict in any manner the use by any
Party of its own documents, information, or materials. If a Designating Party filed Confidential
or Highly Confidential information or material, not under seal and without redaction, its
designation shall be deemed abandoned. Entry of this Order does not foreclose further
agreements by the parties to keep such documents, information, or things confidential or to apply
to the Court for protection of other documents, information, or things.
7.4
Filing Confidential Material. Without written permission from the Designating
Party or a court order secured after appropriate notice to all interested persons, a Party may not
file in the public record in this action any Protected Material. A Party that seeks to file under seal
any Protected Material must follow the procedures set forth in Judge Cathy Seibel’s Individual
Rules & Practices or Judge Victoria Reznik’s Individual Practices in Civil Cases, as appropriate.
VIII. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED IN
OTHER LITIGATION
If a Party is served with a subpoena or a court order issued in other litigation that compels
disclosure of any information or items designated in this action as “CONFIDENTIAL” or
“HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY” that Party must:
(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 to issue in the
other litigation that some or all of the material covered by the subpoena or order is subject to this
Protective Order. Such notification shall include a copy of this Stipulated Protective Order; and
(c) cooperate with respect to all reasonable procedures sought to be pursued by the
Designating Party whose Protected Material may be affected.
If the Designating Party timely seeks a protective order, the Party served with the
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subpoena or court order shall not produce any information designated in this action as
“CONFIDENTIAL” or “HIGHLY CONFIDENTIAL – ATTORNEYS’ EYES ONLY” before a
determination by the court from which the subpoena or order issued, unless the Party has
obtained the Designating Party’s permission. The Designating Party shall bear the burden and
expense of seeking protection in that court of its confidential material – and nothing in these
provisions should be construed as authorizing or encouraging a Receiving Party in this action to
disobey a lawful directive from another court.
IX.
A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE PRODUCED IN
THIS LITIGATION
(a)
The terms of this Order are also applicable to information produced by a Non-
Party in this action and designated as “CONFIDENTIAL” or “HIGHLY CONFIDENTIAL –
ATTORNEYS’ EYES ONLY.” Such information produced by Non-Parties in connection with
this litigation is protected by the remedies and relief provided by this Order. Nothing in these
provisions should be construed as prohibiting a Non-Party from seeking additional protections.
(b)
In the event that a Party is required, by a valid discovery request, to produce a
Non-Party’s confidential information in its possession, and the Party is subject to an agreement
with the Non-Party not to produce the Non-Party’s confidential information, then the Party shall:
1.
promptly notify in writing the Requesting Party and the Non-Party that some or
all of the information requested is subject to a confidentiality agreement with a Non-Party;
2.
promptly provide the Non-Party with a copy of the Stipulated Protective Order in
this litigation, the relevant discovery request(s), and a reasonably specific description of the
information requested; and
3.
make the information requested available for inspection by the Non-Party.
(c)
If the Non-Party fails to respond to the notice or seek a protective order from this
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court within 14 days of receiving the notice and accompanying information, the Receiving Party
may produce the Non-Party’s confidential information responsive to the discovery request. If the
Non-Party timely seeks a protective order, the Receiving Party shall not produce any information
in its possession or control that is subject to the confidentiality agreement with the Non-Party
before a determination by the court.1 Absent a court order to the contrary, the Non-Party shall
bear the burden and expense of seeking protection in this court of its Protected Material.
X.
UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL
If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed Protected
Material to any person or in any circumstance not authorized under this Stipulated Protective
Order, the Receiving Party must immediately (a) notify in writing the Designating Party of the
unauthorized disclosures, (b) use its best efforts to retrieve all unauthorized copies of the
Protected Material, (c) inform the person or persons to whom unauthorized disclosures were
made of all the terms of this Order, and (d) request such person or persons to execute the
“Acknowledgment and Agreement to Be Bound” that is attached hereto as Exhibit A.
XI.
INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE
PROTECTED MATERIAL
If a Party inadvertently produces documents that are privileged, including but not limited
to documents protected by the attorney-client privilege, work product doctrine, or mediation
privilege (together, all inadvertently produced documents shall be a “Privileged Document”),
pursuant to Fed. Rule of Evid. 502(b), production of a Privileged Document shall not be deemed
a waiver of any applicable privilege. Upon discovery that a Privileged Document has been
produced, the Producing Party shall promptly notify the Receiving Party who shall promptly
1
The purpose of this provision is to alert the interested parties to the existence of confidentiality
rights of a Non-Party and to afford the Non-Party an opportunity to protect its confidentiality
interests in this court.
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return or sequester the Privileged Document and all copies of the Privileged Document. If a Party
contends that a Privileged Document has been erroneously designated as such, the party will
nevertheless return to the Party asserting the privilege or sequester the Privileged Document and
all copies of the Privileged Document. The parties reserve the right to contest any determination
that a document is privileged or is otherwise protected from disclosure.
XII.
MISCELLANEOUS
12.1
Right to Further Relief. Nothing in this Order abridges the right of any 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 Protective
Order no Party waives any right it otherwise would have to object to disclosing or producing any
information or item on any ground not addressed in this Stipulated Protective Order. Similarly,
no Party waives any right to object on any ground to use in evidence of any of the material
covered by this Protective Order.
12.3
Modification. This Order may be modified in the event that the parties agree in
writing to a modification of the provisions and such modification is approved by the Court, or
upon either Party’s application to the Court for modification.
12.4
Retention of Jurisdiction. The parties and any other person subject to the terms of
this Stipulation and Order agree that this Court has and retains jurisdiction during this action.
XIII. FINAL DISPOSITION
Within 60 days after the final disposition of this action, as defined above, each Receiving
Party must return all Protected Material to the Producing Party or destroy such material. As used
in this subdivision, “all Protected Material” includes all copies, abstracts, compilations,
summaries, and any other format reproducing or capturing any of the Protected Material.
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Notwithstanding this provision, Counsel are entitled to retain an archival copy of all pleadings,
motion papers, trial, deposition, and hearing transcripts, legal memoranda, correspondence,
deposition and trial exhibits, expert reports, attorney work product, and consultant and expert
work product, even if such materials contain Protected Material. Any such archival copies that
contain or constitute Protected Material remain subject to this Protective Order as set forth
above.
IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD.
DATED: 01/28/2025
/s/ Michelle A. Lamy________
Michelle A. Lamy
LIEFF CABRASER HEIMANN & BERNSTEIN, LLP
Attorneys for Plaintiff
DATED: 01/28/2025
/s/ Maria Papasevastos______
Maria Papasevastos
SEYFARTH SHAW LLP
Attorneys for Defendant
PURSUANT TO STIPULATION, IT IS SO ORDERED.
DATED: January 29, 2025
_____________________________________
The Honorable Victoria Reznik
United States Magistrate Judge
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EXHIBIT A
ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND
I, _________________________________ [print or type full name], of
________________________________________________________ [print or type full address],
declare under penalty of perjury that I have read in its entirety and understand the Stipulated
Protective Order that was issued by the United States District Court for the Southern District of
New York in the case of Graham et al. v. Vassar College, No. 7:23-cv-07692. I agree to comply
with and to be bound by all the terms of this Stipulated Protective Order and I understand and
acknowledge that failure to so comply could expose me to sanctions and punishment in the
nature of contempt. I solemnly promise that I will not disclose in any manner any information or
item that is subject to this Stipulated Protective Order to any person or entity except in strict
compliance with the provisions of this Order.
I further agree to submit to the jurisdiction of the United States District Court for the
Southern District of New York for the purpose of enforcing the terms of this Stipulated
Protective Order, even if such enforcement proceedings occur after termination of this action.
I hereby appoint _________________________________ [print or type full name] of
________________________________________________________ [print or type full address
and telephone number] as my agent for service of process in connection with this action or any
proceedings related to enforcement of this Stipulated Protective Order.
Date: _________________________________
City and State where sworn and signed: _________________________________
Printed name: ______________________________
Signature: __________________________________
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