APP-109E Instructions Proof of Electronic Service (Appellate Division) Clerk stamps date here when form is filed. · This form is only for providing proof that a document has been electronically served (delivered) in a proceeding in the superior court appellate division. · The person who serves (delivers) a document in this case and who fills out this form must be at least 18 years old. · Before you fill out this form, read What Is Proof of Service? (form You fill in the name and street address of the court that issued the decision that is being challenged in this case: APP-109-INFO) to understand your responsibilities. Superior Court of California, County of 1 At the time I served the documents listed in 3 , I was at least 18 years old. a. My home business address is: You fill in the number and name of the trial court case in which the decision being challenged was issued: State Zip 2 Street City Trial Court Case Number: Trial Court Case Name: b. My electronic service address is: 3 I electronically served the following document, as indicated below (check or fill in the name of the document you are serving). Notice of Appeal/Cross Appeal (Limited Civil Case) Notice Designating Record on Appeal (Limited Civil Case) Proposed Statement on Appeal ( Appellant's Opening Brief Respondent's Brief Appellant's Reply Brief Abandonment of Appeal (Limited Civil Case) Petition for Writ (Misdemeanor, Infraction, or Limited Civil Case) Other (write in the name of the document): Limited Civil Case You fill in the appellate division case number (if you know it): Appellate Division Case Number: Misdemeanor Infraction) Judicial Council of California, www.courts.ca.gov New January 1, 2017, Optional Form Proof of Electronic Service (Appellate Division) APP-109E, Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Appellate Division Case Name: Appellate Division Case Number: 4 I electronically served the document checked in 3 as follows a. (1) Name of person served: On behalf of (name or names of parties represented, if person served is an attorney): (2) Electronic service address of person served: (3) On (date): b. (1) Name of person served: On behalf of (name or names of parties represented, if person served is an attorney): (2) Electronic service address of person served: (3) On (date): Check here if you gave copies of the document listed in 3 to more people. Attach a separate page listing the names of these people, the names of parties represented if the person served is an attorney, the electronic service address used for each person served, and the date you electronically served the document. Write "APP-109E, Item 4" on top of the page. 5 Date: I declare under penalty of perjury under California state law that the information above is true and correct. Type or print server's name Server signs here after serving New January 1, 2017 Proof of Electronic Service (Appellate Division) APP-109E, Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com