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(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). a.Complete the Request for Dismissal, form CIV-110. In the top left box of the form print your full name, mailing address and telephone number. If you are the petitioner in a case and you wish to discontinue (dismiss) the case, you may use this form to request that the court dismiss your petition. 0 Dismissal entered as requested on (date): 5 0 Dismissal entered on (date): as to only (name): 6. Form Adopted for Mandatory Use. It can be used in certain civil lawsuits in the Northern District Court of California. This template provides guidance only. This is form CIV-110.