Page 1 of 2 --- Proof of Mailed Service (12/2015) Form H IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF MULTNOMAH Probate Department In the Matter of the Guardianship of Case No. PROOF OF MAILED SERVICE Of Notice of Petition to Appoint Guardian , Of Minor A Minor. (ORS 125.065) , A Minor. I, , Petitioner in this matter, certify that the person(s) served by mail is/are the identical one(s) that I have named below. I served true copies of the following documents: Person Served (Name ) At the following address in County:: Street City/State/ZIP On (date) at Person Served (Name ) At the following address in County:: Street City/State/ZIP On (date) time ) . Person Served (Name ) At the following address in County:: Street City/State/ZIP On (date) at a.m./p.m.( time ) . American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Proof of Mailed Service ( 12/2015) OREGON HEALTH AUTHORITY At the following addr ess: Street 500 Summer St. NE E - 20 City/State/ZIP Salem, OR 97301 On (date) at a.m./p.m.( time ) . DEPARTMENT OF HUMAN SERVICES (DHS) At the following address in County:: Street City/State/ZIP On (date) at a.m./p.m.( time ) . I hereby declare that the above statements are true to the best of my knowledge and belief. I understand that they are made for use as evidence in court and are subject to penalty for perjury. Dated: Signature Street: Print Name: City/State/Zip: Phone Number: American LegalNet, Inc. www.FormsWorkFlow.com