CIV-110

ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NO: FOR COURT USE ONLY
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NO.: FAX NO. :

E-MAIL ADDRESS:

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE

STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:

Plaintiff/Petitioner:
Defendant/Respondent: 3255 TAHQUITZ CANYON WAY

CASE NUMBER:
REQUEST FOR DISMISSAL

A conformed copy will not be returned by the clerk unless a method of return is provided with the document.
This form may not be used for dismissal of a derivative action or a class action or of any party or cause of action in a class
action. (Cal. Rules of Court, rules 3.760 and 3.770.)
1. TO THE CLERK: Please dismiss this action as follows:
a. (1) With prejudice (2) Without prejudice
b. (1) Complaint (2) Petition
(3) Cross-complaint filed by (name): on (date):
(4) Cross-complaint filed by (name): on (date):
(5) Entire action of all parties and all causes of action
(6) Other (specify):*
2. (Complete in all cases except family law cases.)
The court did did not waive court fees and costs for a party in this case. (This information may be obtained from the
clerk. If court fees and costs were waived, the declaration on the back of this form must be completed).
Date:

(TYPE OR PRINT NAME OF ATTORNEY PARTY WITHOUT ATTORNEY) (SIGNATURE)

*If dismissal requested is of specified parties only of specified causes of action only, Attorney or party without attorney for:
or of specified cross-complaints only, so state and identify the parties, causes of Plaintiff/Petitioner Defendant/Respondent
action, or cross-complaints to be dismissed.
Cross Complainant

3. TO THE CLERK: Consent to the above dismissal is hereby given.**

Date:

(TYPE OR PRINT NAME OF ATTORNEY PARTY WITHOUT ATTORNEY) (SIGNATURE)

** If a cross-complaint – or Response (Family Law) seeking affirmative Attorney or party without attorney for:
relief – is on file, the attorney for cross-complainant (respondent) must sign
this consent if required by Code of Civil Procedure section 581 (i) or (j).
Plaintiff/Petitioner Defendant/Respondent
Cross Complainant

(To be completed by clerk)

4. Dismissal entered as requested on (date):
5 Dismissal entered on (date): as to only (name):
6. Dismissal not entered as requested for the following reasons (specify):

7. a. Attorney or party without attorney notified on (date):

b. Attorney or party without attorney not notified. Filing party failed to provide
a copy to be conformed means to return conformed copy
Date: Clerk, by , Deputy Page 1 of 2

Form Adopted for Mandatory Use Code of Civil Procedure, § 581 et seq.; Gov. Code,
Judicial Council of California REQUEST FOR DISMISSAL § 68637(c); Cal. Rules of Court, rule 3.1390
CIV-110 [Rev. Jan. 1, 2013] www.courts.ca.gov
 CIV-110
CASE NUMBER:
Plaintiff/Petitioner:
Defendant/Respondent:

COURT'S RECOVERY OF WAIVED COURT FEES AND COSTS

If a party whose court fees and costs were initially waived has recovered or will recover $10,000 or more in
value by way of settlement, compromise, arbitration award, mediation settlement, or other means, the
court has a statutory lien on that recovery. The court may refuse to dismiss the case until the lien is
satisfied. (Gov. Code, § 68637.)

Declaration Concerning Waived Court Fees

1. The court waived court fees and costs in this action for (name):

2. The person named in item 1 is (check one below):

a. not recovering anything of value by this action.
b. recovering less than $10,000 in value by this action.
c. recovering $10,000 or more in value by this action. (If item 2c is checked, item 3 must be completed.)
3. All court fees and court costs that were waived in this action have been paid to the court (check one): Yes No

I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.

Date:

(TYPE OR PRINT NAME OF ATTORNEY PARTY MAKING DECLARATION) (SIGNATURE)

CIV-110 [Rev. January 1, 2013] REQUEST FOR DISMISSAL Page 2 of 2

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