Order Number:
PLAINTIFF/PETITIONER: CASE NUMBER:
DEFENDANT/RESPONDENT:
AFFIDAVIT OF CUSTODIAN OF RECORDS
(California Evidence Code § 1561)
Records Produced by:
Records Pertaining to:
Date of Birth: Social Security #:
I hereby declare, under penalty of perjury, that the following statements are true and correct to the best of my
knowledge. I, the undersigned, am the duly authorized Custodian of Records (or other qualified witness) for the above
referenced records provider. I have the authority to certify that the records produced herewith pursuant to and
described in the Subpoena / Authorization served with this affidavit are ALL of the records under my control and
custody pertaining to the above named individual(s).
To the best of my knowledge, all of the records referred to above were prepared or compiled by the personnel of the
above named business, in the ordinary course of business, at or near the time of the acts, conditions or events recorded.
I have delivered all of the records / items requested with the following exceptions:
Print Name Signature
Date
Certificati
on of Professional Photocopier
I, the undersigned, declare under penalty of perjury that the foregoing is true and correct and that the attached copy of records was
transmitted or distributed to the authorized person(s) or entities. I further declare that I made true and accurate copies of all records
produced to me by the Custodian of Records of the above named records provider and will maintain the confidentiality of the
information contained within.
Date Signature
These records were originally prepared / created via: (Please check all that apply)
Handwritten notes Transcription Computer generated forms Other
The enclosed records are comprised of the following: (Please check all that apply)
Medical Billing Films/X-Rays Insurance Employment / Payroll
Scholastic Other
