ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, address and telephone #): FOR COURT USE ONLY STATE BAR NO: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF MARIN 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: PROOF OF SERVICE NOTICE OF ADMINISTRATIVE APPEAL - GENERAL Government Code § 53069.4(b)(1) CASE NUMBER: I, _________________________________, hereby declare that I served the Notice of Administrative Appeal (print name) upon the ______________________________________________ and __________________________ by: (name of local agency) (name of counsel) Personally delivering the Notice of Appeal to the address set forth below. Sending the Notice of Appeal by first-class mail to the address set forth below. Local Agency I declare under penalty of perjury and the laws of California that the above is true and correct. The contestant must file the completed Proof of Service form with the court no later than 15 days subsequent to filing Notice of Appeal. Date: ___________________________ ___________________________________________ SIGNATURE CV033WB PROOF OF SERVICE NOTICE OF ADMINISTRATIVE APPEAL - GENERAL Rev. 7/07 American LegalNet, Inc. www.FormsWorkflow.com