Los Angeles local civil form — Proof of Service Notice of Appeal - Administrative Hearing (LASC LACIV 234)

Source: https://lascpubstorage.blob.core.windows.net/forms/Forms%20Comprehensive%20List/LASC%20LACIV%20234.pdf

NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk’s File Stamp

ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS:

CONTESTANT: ADDRESS:

TELEPHONE NUMBER: PROCESSING AGENCY: ADDRESS:

TELEPHONE NUMBER: CASE NUMBER: PROOF OF SERVICE NOTICE OF APPEAL - ADMINISTRATIVE HEARING

1. At the time of service I was over 18 years of age.

2. My residence or business address is: ___________________________________________________________
_________________________________________________________________________________________

3. Citation Number of case being appealed: ______________________________________________________.

4. Type of Service:

BY MAIL
On __________________________, I served the Notice of Appeal – Administrative Hearing, in this case
(DATE)
by placing a copy thereof, enclosed in a separate, sealed envelope with first class postage prepaid, in the

United States mail at _____________________________, in the county of _______________________,
(CITY)
State of California, said envelope having been addressed as follows:
Processing Agency:
Street address:
City, State, Zip Code:

At the time of mailing, I was employed or resided in the county where said mailing occurred.

PERSONAL SERVICE
On __________________________, I personally delivered a copy of the Notice of Appeal –
(DATE)
Administrative Hearing, to the Processing Agency at the address below:

Processing Agency:
Street address:
City, State, Zip Code:

5. Executed on ______________________________ at __________________________________, California.
(DATE) (CITY)
I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct.

Dated: _________________________ __________________________________________________________SIGN Signature of Contestant

LACIV 234 (NEW) SCLAC Approved: 04-26 PROOF OF SERVICE Gov. Code, § 53069.4 For Optional Use NOTICE OF APPEAL - ADMINISTRATIVE HEARING