ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, address and telephone #): FOR COURT USE ONLY STATE BAR NO: ATTORNEY FOR (Name): MARIN COUNTY SUPERIOR COURT 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: ADMINISTRATIVE APPEAL - GENERAL PROOF OF SERVICE Government Code § 53069.4(b)(1) CASE NUMBER: At the time of service, I was at least 18 years of age, not a party to the action, and I served the Notice of Administrative Appeal to NAME OF AGENCY on at __________ AM / PM by: Leaving document(s) with _______________________________________________ at the address below. NAME OF PERSON Sending document(s) by first-class mail to the address below. Address: The appellant must file the completed Proof of Service form with the court no later than 15 days subsequent to filing Notice of Appeal. If appellant plans to subpoena a government official to be present at the hearing, obtain from the court a civil subpoena form. The appellant must present this form to the issuing agency and pay a subpoena fee of $275.00 per day (Government Code § 68097.2). I declare under penalty of perjury and the laws of the State of California that the above is true and correct. DATE PRINT NAME OF SERVER SIGNATURE OF SERVER CV033 ADMINISTRATIVE APPEAL - GENERAL - PROOF OF SERVICE Rev. 6/2/15 American LegalNet, Inc. www.FormsWorkFlow.com