[name of contact]                 )
[street address]                  )
[city], CA  92801                 )
(714) 555-1212                    )
[email address]                   )
Plaintiff                         )
In propria Persona                )
                                  )
                                  )
                                  )
----------------------------------)-------------------------

         SUPERIOR COURT OF THE STATE OF CALIFORNIA
              IN AND FOR THE COUNTY OF ORANGE

[your name],                      )   CASE NO.  00-00-00
                                  )   
     Plaintiff,                   )   [title of paper]
                                  )   [purpose of paper]
        vs.                       )                    
                                  )   [other information such as
[defendant name,                  )   VERIFIED
John Doe, and                     )   EX PARTE]
Mary Roe,                         )   
                                  )   
     Defendants.                  )    Date:  
                                  )    Dept:  
             Defendants,          )   Judge: 
----------------------------------)-------------------------

                                  _____________________________
                                  Robert Melvin Anderson
                                  Plaintiff