Fill and Sign the California Abuse Form

EA-141 Proof of Service by Mail 1 Name of person asking for protection: ––––– 2 Your name: ––––– 3 Notice to Server The server must: • Be over 18 years of age. • Be a resident or employed in the county where the mailing took place. • Not be listed on the restraining order. • Mail a copy of all documents checked in m to the person in j Complete and signthis form : and give it to the person in k PROOF OF SERVICE BY MAIL 4 I am over 18 years of age and am a resident or employed in the county where the mailing took place. I mailedthe person in j a copy of all documents checked below: a. Form EA-110, Response to Request for Orders to Stop Elder or Dependent Adult Abuse (completed) b. Other (specify): ––––– 5 I placed copies of the documents checked above in a sealed envelope and mailed them as described below: a. Mailed from (City): ––––– (State): ––––– b. On (Date): ––––– c. To this Address: ––––– City: ––––– State: ––––– Zip: ––––– 6 Server's Information Name: ––––– _______________________________________________________________________________ Address: ––––– City: ––––– State: ––––– Zip: ––––– Telephone: ––––– _ (If you are a registered process server): County of registration: ––––– Registration number: ––––– I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Superior Court of California, County of ––––– ––––– ––––– ––––– ––––– Case Number : –––––Clerk stamps date here when form is filed . Fill in court name and street address: Court fills in case number when form is filed. Date: ––––– ––––– Type or print server’s name Server signs here Judicial Council of California, www.courtinfo.ca.gov Rev. January 1, 2007, Optional Form Welfare & Institutions Code, § 15657.03 Proof of Service by Mail—CLETS (Elder and Dependent Adult Abuse Prevention) EA-141, Page 1 of 1 electronic form ã 2007 WWW.LawCA.co m Law Publishers