Dwc District Office California Form Pack (Page 22 of 22) in pdf

Dwc District Office California Form Pack Page 22

SAMPLE

Proof Of Service By Mail

I declare that:

YOUR COUNTY

I am (resident of/employed in) the county of _______________ California. I am

over the age of eighteen years, my (business/residence) address is:

PUT YOUR HOME ADDRESS HERE

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

TODAY'S DATE

NAME OF DOCUMENT

On ____________, I served the attached _______________________ on the

INSURANCE COMPANY

________________ in said case, by placing a true copy thereof enclosed in a

sealed envelope with postage thereon fully paid, in the United State mail at

CITY WHERE YOU MAILED THIS

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ a d d r e s s e d a s f o l l o w s _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I declare under penalty of perjury under the laws of the State of California that the

foregoing is true and correct, and that this declaration was executed on

TODAY'S DATE

CITY

( d a t e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , a t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ C a l i f o r n i a .

PRINT YOUR NAME

T y p e o r p r i n t n a m e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

SIGN YOUR NAME

S i g n a t u r e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Dwc District Office California Form Pack Page 22