Fill and Sign the Appellate Division Form

APP-109 Proof of Service Clerk stamps date here when form is filed. (Appellate Division) Instructions • This form is only for providing proof that a document has been served (delivered) in a proceeding in the superior court appellate division. • The person who serves (delivers) a document in this case and who fills out this form: ° Must be at least 18 years old ° Must NOT be a party in this case You fill in the name and street address of the court that issued the decision that is being • Before you fill out this form, read What Is Proof of Service? (form challenged in this case: APP-109-INFO) to understand your responsibilities. Superior Court of California, County of ––––– ––––– ––––– 1 At the time I served the documents listed in 4 , I was at least 18 years old. ––––– ––––– 2 I am not a party in the case identified in the box on the right side of this page. You fill in the number and name of the trial court case in which the decision being challenged was issued: 3 My home business address is: ––––– Trial Court Case Number: ––––– ––––– ––––– ––––– ––––– Street City State Zip Trial Court Case Name: 4 I mailed or personally delivered the following document, as indicated ––––– below (check or fill in the name of the document you are serving and You fill in the appellate division case number (if check and complete either a or b). you know it): Notice of Appeal/Cross Appeal (Limited Civil Case) Appellate Division Case Number: ––––– Notice Designating Record on Appeal (Limited Civil Case) Proposed Statement on Appeal ( Limited Civil Case Misdemeanor Infraction) Appellant’s Opening Brief Respondent’s Brief Appellant’s Reply Brief Abandonment of Appeal (Limited Civil Case) Petition for Writ (Misdemeanor, Infraction, or Limited Civil Case) Other (write in the name of the document): ––––– ––––– ––––– a. Service by Mail (1) I put one copy of the document identified in 4 in an envelope addressed to each person listed in (2), sealed the envelope, and put first-class postage on the envelope. Judicial Council of California Proof of Service APP-109 , Page 1 of 2 New January 1, 2009, Optional Form (Appellate Division) elec troni c form ã 2009 WWW.LawCA.co m L a w P u b l i s h e r s Appellate Division Case Number: Appellate Division Case Name: ––––– ––––– (2) The envelope or envelopes were addressed as follows: (a) Name of person served: ––––– Address on envelope: ––––– ––––– ––––– ––––– Street City State Zip ((b) Name of person served: ––––– Address on envelope: ––––– ––––– ––––– ––––– Street City State Zip Check here if you mailed copies of the document identified in 4 to more people. Attach a separate page listing the names and addresses on each additional envelope you mailed. Write “APP-109, Item 4a” on the top of the page. (3) I mailed the envelope or envelopes on (date): ––––– from (city, state): ––––– by depositing the envelope or envelopes (check one): (a) With the U.S. Postal Service or (b) At an office or business mail drop where I know the mail is picked up every day and deposited with the U.S. Postal Service. b. Service by Personal Delivery I personally gave one copy of the document identified in 4 to each of the following people: (1) (a) Name of person served: ––––– (b) Address where you gave the documents to this person: ––––– Street ––––– ––––– ––––– ––––– City State Zip (c) Date when you gave the documents to this person: ––––– (d) Time when you gave the documents to this person: ––––– (2) (a) Name of person served: ––––– (b) Address where you gave the documents to this person: ––––– Street ––––– ––––– ––––– ––––– City State Zip (c) Date when you gave the documents to this person: ––––– (d) Time when you gave the documents to this person: ––––– Check here if you gave copies of the document identified in 4 to more people. Attach a separate page listing the names of each of these people, the address where you gave each of them the document, and the date and time you gave them the document. Write “APP-109, Item 4b” on the top of the page. 5 I declare under penalty of perjury under California state law that the information above is true and correct. Date: ––––– ––––– Type or print server’s name Server signs here after serving New January 1, 2009 Proof of Service APP-109 , Page 2 of 2 (Appellate Division)