Mendocino — SC-104A

Source: http://www.courts.ca.gov/documents/sc104a.pdf

Case Number: SC-104A Proof of Mailing (Substituted Service)

þ 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

www.courts.ca.govJudicial Council of California,

Revised January 1, 2006, Optional Form Proof of Mailing (Substituted Service) SC-104A, Page 1 of 1 Code of Civil Procedure, §§ 116.340, 415.20 (Small Claims) For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form