ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY TELEPHONE NUMBER: FAX NO. (Optional): EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1035 Palm Street, Room 385 Same as above San Luis Obispo, CA 93408 San Luis Obispo Division LPS CONSERVATORSHIP OF: CASE NUMBER: DECLARATION OF SERVICE ON PETITION FOR REAPPOINTMENT OF LPS CONSERVATOR I, __________________ (print name), am at all times herein mentioned a citizen of the United States and resided at ______________________________________(address). I am over the age of 18 and NOT a party to this action. I gave or mailed a copy of the petition for Reappointment of LPS Conservator as follows: On _________, _____ Gave a copy of the above San Luis Obispo County Director of Mental Health (month/date/ year). documents to Or mailed, 2180 Johnson Ave, 2nd Floor a copy of the above San Luis Obispo, CA 93401 documents to: On _________, _____ Gave a copy of the above San Luis Obispo County Public Guardian (month/date/ year). documents to Or mailed, P.O. Box 1489 a copy of the above San Luis Obispo, CA 93406 documents to: On _________, _____ Gave a copy of the above Maguire and Ashbaugh San Luis Obispo County Public (month/date/ year). documents to Or mailed, Defender a copy of the above 991 Osos Street, Suite A documents to: San Luis Obispo, CA 93401 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR012 Rev. 1/1/15 DECLARATION OF SERVICE Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com LPS CONSERVATORSHIP OF: CASE NUMBER On _________, _____ (month/date/ year). Gave a copy of the above documents to Or mailed, a copy of the above documents to: Conservatee (list address) **NOTE citation must also be personally served** On _________, _____ (month/date/ year). Gave a copy of the above documents to Or mailed, a copy of the above documents to: (Care facility- list address) On _________, _____ (month/date/ year). Gave a copy of the above documents to Or mailed, a copy of the above documents to: (Any others, such as family, or private attorney of conservatee- list address) On _________, _____ (month/date/ year). Gave a copy of the above documents to Or mailed, a copy of the above documents to: (Any others, such as family, or private attorney of conservatee- list address) On _________, _____ (month/date/ year). Gave a copy of the above documents to Or mailed, a copy of the above documents to: (Any others, such as family, or private attorney of conservatee- list address) Other parties served are listed on Attachment 1. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ________________ _____________________________ (Print Name) Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR012 Rev. 1/1/15 ______________________________ (Signature of party serving notice) Page 2 of 2 DECLARATION OF SERVICE American LegalNet, Inc. www.FormsWorkFlow.com