Qme Form 110 - Qme Appointment Notification Form Page 2
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1
2Declaration of Service
I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of
eighteen years and I am not a party to this case, my business or residence address is:
On
, I served this QME Appointment Notification Form, the original, or a true and correct copy
of the original, which is attached, on each of the persons or firms named below, by placing it in a sealed envelope,
addressed to the person or firm named below, and by:
A
depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.
placing the sealed envelope for collection and mailing following our ordinary business practices. I am
readily familiar with this business’s practice for collecting and processing correspondence for mailing. On
B
the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary
course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid.
placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop
C
box of the overnight delivery carrier.
placing the sealed envelope for pick up by a professional messenger service for service. (Messenger must
D
return to you a completed declaration of personal service.)
E
personally delivering the sealed envelope to the person or firm named below at the address shown below.
Person or firm served
Street Address
Method of
Service
City
State
Zip Code
Person or firm served
Street Address
Method of
Service
City
State
Zip Code
Person or firm served
Street Address
Method of
Service
City
State
Zip Code
Person or firm served
Street Address
Method of
Service
City
State
Zip Code:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
at
, California.
Type or print name
Signature _____________________________________________
QME Form 110 (rev. 10/2013)
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