Request For Confidential Mediation Regarding Visitation Page 4
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4PR-E-LP-025
Proof of Service
1.
I am over the age of 18 and not a party to this cause. My residence or business address is:
2.
I am a resident of or employed in the county where the mailing occurred. I serviced a copy of the Petition for
Confidential Mediation by mailing them, in a sealed envelope with postage fully prepaid, as follows:
a.
I deposited the envelope with the United States Postal Service.
b.
Date of deposit: _______________ c.
Place of deposit (city and state: _______________
d. Address at which person service: ____________________________________________________
e. On (date): ___________________
f. At (time): _____________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
______________________________
________________________________________________
TYPE OR PRINT NAME
SIGNATURE OF DECLARANT
4 of 4
Page
PR-E-LP-025 (Revised 1/11/16)
Request for Confidential Mediation Regarding Visitation
Local Rule 4.33
Mandatory
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