Form App 008 – Fill Out and Use This PDF

	TO BE FILED IN THE COURT OF APPEAL		APP-008
			COURT OF APPEAL CASE NUMBER:
COURT OF APPEAL	APPELLATE DISTRICT, DIVISION
ATTORNEY OR PARTY WITHOUT ATTORNEY:	STATE BAR NUMBER:		SUPERIOR COURT CASE NUMBER:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY:	STATE:	ZIP CODE:
TELEPHONE NO.:	FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):

APPELLANT/

PETITIONER:

RESPONDENT/

REAL PARTY IN INTEREST:

CERTIFICATE OF INTERESTED ENTITIES OR PERSONS

(Check one):

INITIAL CERTIFICATE

SUPPLEMENTAL CERTIFICATE

Notice: Please read rules 8.208 and 8.488 before completing this form. You may use this form for the initial certificate in an appeal when you file your brief or a prebriefing motion, application, or opposition to such a motion or application in the Court of Appeal, and when you file a petition for an extraordinary writ. You may also use this form as a supplemental certificate when you learn of changed or additional information that must be disclosed.

1. This form is being submitted on behalf of the following party (name ):

(2)

(3)

(4)

(5)

Continued on attachment 2.

The undersigned certifies that the above-listed persons or entities (corporations, partnerships, firms, or any other association, but not including government entities or their agencies) have either (1) an ownership interest of 10 percent or more in the party if it is an entity; or (2) a financial or other interest in the outcome of the proceeding that the justices should consider in determining whether to disqualify themselves, as defined in rule 8.208(e)(2).

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF APPELLANT OR ATTORNEY)

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