Declarant is a competent witness over the age of 18 years of age,has personal knowledge of the stated facts, and does Solemnly state that:

1. I personally Served a legible copy of the document entitled, "Notice of Applicable California law concerning The Department of the California Highway Patrol." upon a person who was purporting to be a officer of the CALIFORNIA HIGHWAY PATROL in my presence by [line out any items which do not apply]:

a. approaching me and/or my vehicle at (location) ___________________________________________________________________________.

b. wearing or displaying a badge reading CALIFORNIA HIGHWAY PATROL, TRAFFIC CONTROL OFFICER, (badge number) __________________.

c. wearing the uniform I believe to have been formerly associated with the California Highway Patrol.

d. driving, or riding in, a vehicle bearing the markings HIGHWAY PATROL and (vehicle license plate No.) EXEMPT_______________________________________.

e. Verbally identifying himself/herself as an officer of the California Highway Patrol and as (name): _____________________________________________________.

I Certify under the law of the State of California, that I have read this document and that it is complete and accurate.

Signature (of declarant/server): _______________________________________________________.

Dated: ________________________________________________.

At: ____________________________________________________

Signature(s) of Witnesse(s) [if witnesses available]:

______________________________________________.

______________________________________________.

[Note: This page is an attachment to the document entitled, Notice of Applicable California law concerning The Department of the California Highway Patrol. and should be retained by the server after service of said document.]