LASC MH 005 Rev 11/18 For Optional Use SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES Reserved for Clerk222s File Stamp COURTHOUSE ADDRESS: PLAINTIFF/PETITIONER: CONSERVATEE: DECLARATION OF SERVICE Case Number: I the undersigned hereby declare under penalty of perjury that the following is true and correct: That I have delivered or mailed a copy of the Petition for Re-appointment and Notice of Hearing to the following agencies on the date indicated: MailedHand-DeliveredDate: Director of Health, State of California Bureau of Patients222 Accounts 1600 Ninth Street, 2nd Floor South Sacramento, CA 95814 MailedHand-DeliveredDate: Los Angeles County Public Defender 1945 S. Hill Street, 2nd Floor Los Angeles, CA 90007 MailedHand-DeliveredDate: Conservatee: C/O (Facility Name) Address MailedHand-DeliveredDate: Facility Address MailedHand-DeliveredDate: Any Other Executed on at , California Signature of Conservator American LegalNet, Inc. www.FormsWorkFlow.com