NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk's File Stamp ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: CONTESTANT: ADDRESS: TELEPHONE NUMBER: PROCESSING AGENCY: ADDRESS: TELEPHONE NUMBER: PROOF OF SERVICE NOTICE OF APPEAL - ADMINISTRATIVE HEARING 1. At the time of service I was over 18 years of age. CASE NUMBER: 2. My residence or business address is: ___________________________________________________________ _________________________________________________________________________________________ 3. Citation Number of case being appealed: ______________________________________________________. 4. Type of Service: BY MAIL On __________________________, I served the Notice of Appeal ­ Administrative Hearing, in this case (DATE) by placing a copy thereof, enclosed in a separate, sealed envelope with first class postage prepaid, in the United States mail at _____________________________, in the county of _______________________, (CITY) State of California, said envelope having been addressed as follows: Processing Agency: Street address: City, State, Zip Code: At the time of mailing, I was employed or resided in the county where said mailing occurred. PERSONAL SERVICE On __________________________, I personally delivered a copy of the Notice of Appeal ­ (DATE) Administrative Hearing, to the Processing Agency at the address below: Processing Agency: Street address: City, State, Zip Code: 5. Executed on ______________________________ at __________________________________, California. (DATE) (CITY) I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct. Dated: _________________________ __________________________________________________________ Signature of Contestant Gov. Code, § 53069.4 American LegalNet, Inc. www.FormsWorkFlow.com LACIV 234 (NEW) LASC Approved: 06-12 For Optional Use PROOF OF SERVICE NOTICE OF APPEAL - ADMINISTRATIVE HEARING