Proof of Service By Mail I declare that: I am a resident of or employed in the county where the mailing took place. I am over the age of eighteen years, my business or residence address is: On , I served the attached Replacement Panel Order the in said case, by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United States mail, addressed as follows: Division of Workers' Compensation-Medical Unit P.O. Box 71010 Oakland, CA 94612 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration was executed on: Date: at , California. City Type or print name Signature _____________________________________________ Unrepresented replacement panel -2014 American LegalNet, Inc. www.FormsWorkFlow.com