NAME AND ADDRESS OF ATTORNEY: TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR: Insert Name of Court, Judicial District or Branch Court, if any, and Post Office and Street Address: PLAINTIFF(S), PETITIONER(S): DEFENDANT(S), RESPONDENT(S) CASE NUMBER: PROOF OF SERVICE BY MAIL Hearing: Date Time Dept. I am over the age of 18 and not a party to this action. I am a resident of or employed in the county where the mailing occurred. My residence or business address is: I served a copy of the following documents (list documents): by placing a true copy of each document in the United States mail, in a sealed envelope with postage fully prepaid, as follows: a. Date of deposit: b. Place of deposit (city and state): c. Addressed as follows: I declare under penalty of perjury that the foregoing is true and correct and that this declaration is executed on (date) , at (place) , California. TYPE OR PRINT NAME SIGNATURE Clerk 580 2170 Cl 22 (12-83) PROOF OF SERVICE BY MAIL KN-22 2002 © American LegalNet, Inc.