_______________, [declares under penalty of perjury:] That [s]he is [a party] [attorney for a party] to the above-captioned adjudicatory proceeding. That [declarant] believes that [s]he cannot have a [fair] [expeditious] hearing before Administrative Law Judge [to whom the proceeding is assigned]. That declarant [or the party declarant represents] has not filed, pursuant to Rule 9.2, any prior motion for reassignment on peremptory challenge in the proceeding. Dated _______________, at ________________, California. ____________________ [Signature]

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