This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts. STATE OF ILLINOIS , CIRCUIT COURT COUNTY PROOF OF DELIVERY For Court Use Only I nstructions Plaintiff / Petitioner ( First, middle, last name or Company ) v. Defendant / Respondent ( First, middle, last name ) Directly above, enter the name of the county where the case was filed. Enter the name of the person or company that filed this case as Plaintiff/Petitioner. Case Number Enter the name of the Defendant/Respondent. Enter the Case Number given by the Circuit Clerk. In 1, enter the name of the court document you are sending to the other parties in the court case (e.g., a Court Order or Answer). In 1a, enter the name, mailing address, and email address of the party or lawyer to whom you sent the document. In 1b, check the box to show how you sent the document, and fill in any other information required on the blank lines. CAUTION: If the other party does not have a lawyer, you may send the document by email only if the other party has listed their email address on a court document. In c, fill in the date and time that you sent the document. In 2, if you sent the document to more than 1 party or lawyer, fill in a, b, and c. Otherwise leave 2 blank. 1.003 I am sending the following court document: a.003 To:002 Name:002 First003 Middle Last Address: Street , Apt #003 City State ZIP Email address: b.003 By: Personal hand delivery Regular, First - Class Mail, put into the U.S. Mail with postage paid at: Address of Post Office or Mailbox Third - party commercial carrier, with delivery paid for at: Name (for example, FedEx or UPS ) and office address The court's electronic filing manager (EFM) or an approved electronic filing service provider (EFSP) Email (not through an EFM or EFSP) Mail from a prison or jail at: Name of prison or jail c. On: Date At: a.m. p.m. Time 2. I sent this document: a. To: Name: First Middle Last Address: Street , Apt # City State ZIP Email address: PD - P 803. 4 Page 1 of 2 ( 03 /1 9 ) American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: b. By: Personal hand delivery 000F Regular, First - Class Mail, put into the U.S. Mail with postage paid at: Address of Post Office or Mailbox 000F Third - party commercial carrier, with delivery paid for at: If you sent your document to more than 2 parties or lawyers, check the box and file the Additional Proof of Delivery with this form Under the Code of Civil Procedure, 735 ILCS 5/1-109, making a statement on this form that you know to be false is perjury, a Class 3 Felony. If you are completing this form on a computer, sign your name by typing it. If you are completing it by hand, sign and print your name. Name (for example, FedEx or UPS ) and office address The court's electronic filing manager (EFM) or an approved electronic filing service provider (EFSP) Email (not through an EFM or EFSP) Mail from a prison or jail at: Name of prison or jail c. On: Date At: a.m. p.m. Time I have completed an Additional Proof of Delivery form. I certify that everything in the Proof of Delivery is true and correct. I understand that making a false statement on this form is perjury and has penalties provided by law under 735 ILCS 5/1 - 109 . /s/ Your Signature Street Address Print Your Name City, State, ZIP Telephone PD - P 803.4 Page 2 of 2 ( 03 /1 9 ) American LegalNet, Inc. www.FormsWorkFlow.com