Form Dwc-Ad 10003 - Notice Of Offer Of Regular Work (Page 7 of 7) in pdf

Form Dwc-Ad 10003 - Notice Of Offer Of Regular Work Page 7

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK

For injuries occurring on or after 1/1/04

Proof of Service By Mail

I am a citizen of the United States and a resident of the County of _______________________________. I

am over the age of eighteen years and not a party to the within matter.

My business address is:

________________________________________________________________________________________

___

On _________________________________, I served the Notice of Offer of Modified or Alternative Work

on the parties listed below by placing a true copy thereof enclosed in a sealed envelope with postage fully

prepaid, and thereafter deposited in the U. S. Mail at the place so addressed.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed at ___________________________on __________________.

Signature:____________________________________

Copies Served On:

MANDATORY FORM (Page

)

STATE OF CALIFORNIA

(08/06)

Form Dwc-Ad 10003 - Notice Of Offer Of Regular Work Page 7