Fill and Sign the Substituted Service Form

Case Number: SC-104A Proof of Mailing (Substituted Service) ––––– This form is attached to Form SC-104. Use this form ONLY if you mailed the documents in 1 and someone else personally gave them to the person, business , or public entity served. Notice to Server You must: • Be at least 18 and not listed in this lawsuit. • Fill out 1 – 6 of this form and attach it to Form SC-104. 1 Documents served by mail: a. SC-100, Plaintiff’s Claim and ORDER to Go to Small Claims Court b. SC-120, Defendant’s Claim and ORDER to Go to Small Claims Court c. Other (specify): ––––– ––––– 2 Name and address of the person, business, or public entity served: a. If you served a person, write the person’s name and address below: Name: ––––– Address: ––––– Street City State Zip b. If you served a business or public entity, write the name and address of the business or public entity, the person authorized for service, and that person’s job title: ––––– Business or Public Entity Name Person Authorized for Service Job Title Address: ––––– Street City State Zip 3 I put copies of the documents listed in 1 above in an envelope, sealed the envelope, and put first-class prepaid postage on it. I addressed the envelope to the person, business, or public entity listed in 2 and mailed the envelope by leaving it at (check one): a. A U.S. Postal Service mail drop or b. An office or business mail drop where I know the mail is picked up every day and deposited with the U.S. Postal Service . 4 I mailed the envelope: a. On (date): ––––– b. From (city, state): ––––– 5 My address is: ––––– 6 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 mailing Judicial Council of California, SC-104A, Page 1 of 1 Revised January 1, 2006, Optional Form Code of Civil Procedure, §§ 116.340, 415.20 Proof of Mailing (Substituted Service) (Small Claims) electronic form ã 2005 WWW.LawCA.co m Law Publishers