Form 4a-104 - Judicial District Court Page 2
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2___________________________________
Name
___________________________________
Mailing address
___________________________________
City, State, Zip
___________________________________
Physical Address (this must be provided unless
address is sealed by court order)
___________________________________
City, State, Zip
___________________________________
Telephone number
I hereby certify that a true and correct copy
of this Response was mailed to
Petitioner/Petitioner’s counsel at _________________
_________________ (address)
on ________________ (date).
____________________________________
Signature of Respondent
[Approved by Supreme Court Order No. 13-8300-010, effective for all pleadings and papers filed
on or after May 31, 2013, in all cases pending or filed on or after May 31, 2013.]
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