Information Release Authorization {VN043}

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Superior Court of California, County of Ventura Calendar No. FAMILY COURT SERVICES HALL OF JUSTICE : JUDICIAL SUBPOENA Plaintiff(s) 800 South Victoria Avenue Ventura, California: 93009 -against(805) 662-6694 : Fax: (805) 654-2240 : Index No. Defendant(s) : ...................................................... INFORMATION RELEASE AUTHORIZATION THE PEOPLE OF THE STATE OF NEW YORK TO I/We, / , specifically authorize any public agency, private person or medical doctor, psychologist, treating GREETINGS: therapist, or hospital possessing information about me or my minor children, confidential COMMAND YOU, that all business and excuses being copies) to the Superior Court before WE or otherwise, to release same (including laid aside, you and each of you attend , the Honorable at the Court through its duly appointed court investigator. Such information to be used as the court County of fit and proper for located at may deem determination of guardianship. This release includes but in room limited to,on the , treatmentday ofdrug and/or20 , alcohol abuse and/or the , at o'clock in psychiatric and at any recessed noon, treatment, is not for or adjourned date, to testify and give evidence as a witness in this action on the part of the employment records and bank records. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 Date Signature Proposed Guardianbelow) (Attorney must sign above and type name Date Signature Proposed Co-Guardian Attorney(s) for Office and P.O. Address Optional Form VN043 Rev. 01/01/04 Telephone No.: Facsimile No.: This authorization is effective for one year from the date of signature. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com