REQUEST FOR SUBMISSION

I respectfully request that the   Title of Motion file on   Date filed be:
Submitted for judicial review;   
Hearing requested.        

I verify the following:

(1) The motion was served upon the other party (or parties) to this case on   Date served   by the following means:

Dated:   Date   
Signature:   Signature   
Print Name:   Print Name   
Address:   Address   
City, State, Zip:   City, State, Zip   
Telephone:   Telephone   
Email:   Email Address   

Pursuant to JCRCP 5(b), I hereby certify that on this   day/ddof   month/MM, 20YY, I served a true and correct copy of the foregoing Request for Submission upon the following people:         

Name: Name   
Address: Address City, State, Zip                            

Name:Name   
Address:AddressCity, State, Zip   

Name: Name   
Address: Address  City, State, Zip   

Dated:   Date   
Signature:   Signature   
Print Name:   Print Name