Your physical or electronic signature
A description of the item that was taken down
The item number or URL of the item before it was taken down
A statement under penalty of perjury that you have a good faith belief that the material was removed or disabled as a result of mistake or misidentification of the item to be removed or disabled.
Your name, address and telephone number, and
A statement that you consent to the jurisdiction of the federal district court where your address is located (or if you reside outside the United States, that you consent to jurisdiction in San Francisco, California), and that you will accept service of process from the person who provided notification under 17 U.S.C. Section 512 (c)(1)(C) or an agent of such person