Form Laciv 234 Notice Of Appeal - Administrative Hearing
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1NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NUMBER
Reserved for Clerk’s File Stamp
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
COURTHOUSE ADDRESS:
CONTESTANT:
ADDRESS:
TELEPHONE NUMBER:
PROCESSING AGENCY:
ADDRESS:
TELEPHONE NUMBER:
PROOF OF SERVICE
CASE NUMBER:
NOTICE OF APPEAL - ADMINISTRATIVE HEARING
1. At the time of service I was over 18 years of age.
2. My residence or business address is: ___________________________________________________________
_________________________________________________________________________________________
3. Citation Number of case being appealed: ______________________________________________________.
4. Type of Service:
BY MAIL
On __________________________, I served the Notice of Appeal – Administrative Hearing, in this case
(DATE)
by placing a copy thereof, enclosed in a separate, sealed envelope with first class postage prepaid, in the
United States mail at _____________________________, in the county of _______________________,
(CITY)
State of California, said envelope having been addressed as follows:
Processing Agency:
Street address:
City, State, Zip Code:
At the time of mailing, I was employed or resided in the county where said mailing occurred.
PERSONAL SERVICE
On __________________________, I personally delivered a copy of the Notice of Appeal –
(DATE)
Administrative Hearing, to the Processing Agency at the address below:
Processing Agency:
Street address:
City, State, Zip Code:
5. Executed on ______________________________ at __________________________________, California.
(DATE)
(CITY)
I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct.
Dated: _________________________
__________________________________________________________
Signature of Contestant
LACIV 234 (NEW)
Gov. Code, § 53069.4
PROOF OF SERVICE
LASC Approved: 06-12
NOTICE OF APPEAL - ADMINISTRATIVE HEARING
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