Preview
Proof of Service
, we cu rp
I Sha
Use this form to serve a person, a business, or a public entity. To leam more
about proof of service, read What Is "Proof of Service"?, Form SC-104B. To
learn more about how to serve a business or entity, read How to Serve a
Business or Public Entity, Form SC-104C.
To serve a business, you must serve one of the following people:
* Owner (for a sole proprietorship)
+ Partner (for a partnership) or general partner (for a limited partnership)
+ Any officer or general manager (corporation or association)
* Any person authorized for service by the business (corporation, association,
general partnership, limited partnership)
« Any person authorized for service with the Secretary of State (corporation,
association, limited liability company [LLC], limited liability partnership
[LLP], limited partnership)
To serve a public entity, you must first file a claim with that entity, then
serve one of the following people:
* Clerk (of a city or county)
* Chief officer or director (of a public agency)
« Any person authorized for service by the entity
@) “ME 1 are Sery) iat a person, write the person’s name below:
lavcela 2. Buyciages
b. If you are serving a business or entity, write the name of the business
or entity, the person authorized for service, and that person’s job title:
. f
Business or Agency Name
Person Authorized for Service
Job Title
@) Instructions to Server:
2OIGFEB £1 AM 10: 04
ROSA suspugga get
Pury
Fill in court name and street address:
Superior Court of California, County of
SAN JOAQUIN
222 EAST WEBER AVENUE
STOCKTON.CALIFORNIA 95201
Fill in case number, case name, hearing date,
day, time, and department below:
Case Number:
STK-CV-SC-2016- 0.00088.
Case Name:
Dameron Hospital Association, A
Comp VS.Mavce/a A Buyeiago
Hearing Date: 02-2 Q- 2 ol
“| Time: \.30PM Dept: a eX
You must be at least 18 years old and not be named in this case, Follow these steps:
“» Give a copy of all the documents checked in @) to the person in @, or
* Give a copy of all the documents checked in@) to one of the following people:
a. A competent adult (at least 18) living with, and at the home of the person in
), OF
b. An adult (at least 18) who seems to be in charge at the usual workplace of the person in @, or
¢. An adult (at least 18) who seems to be in charge where the person in @®
usually receives mail
{but not a U.S. Post Office box), if there is no known physical address for the person in@.
and mail a copy of the documents left with one of the adults in a, b, or ¢ above to the person in).
THEN
+ Complete and sign this form, and
+ Give or mail your completed form to the person who asked you to serve these court papers, in tine for
the form to be filed with the court at least 5 days before the hearing.
@) I served the person in @ a copy of the documents checked below:
a. SC-100, Plaintiff's Claim and ORDER to Go to Small Claims Court
b. O sc-120, Defendant's Claim and ORDER to Go to Small Claims Court
hal)
c. Order for examination (This form must be personally served. Check the form that was serve ed):
Note: The court can issue a civil arrest warrant if the served party does not come to court only if the order for
examination was personally served by a registered process server, sheriff, marshal, or Someone appointed by the court. *~
(1) C1 SC-134, Application and Order to Produce Statement of Assets and to Appear for Examination
(2) EL] AT-138/EJ-125, Application and Order for Appearance and Examination
d. OF Other (specify):
Judicial Councal of Catfomnia, wawy.courinfo.ca gov
Revised January 1, 2009, Optional Foam
Code of Civil Procedure, §§ 116.340, 415.10, 415.20
Proof of Service
(Smail Claims)
“$C-104, Page 1 of 2
>a)
We
. Case Namber
. soe . 2.
Case name: Dameron Hospital Association Vs.Mavvela f, Buyciaq STK-CV-SC-2016- 20 8.
(4) Fill out “a” or “b” below:
a. [1] Personal Service: I personally gave copies of the documents checked in @) to the person in (4):
On (date): * At (time): Olam. Opm.
At this address:
City: State: Zip:
b. Substituted Service: | personally gave copies of the ddcuments checked in @) (a, b, or d) to (check one):
(1A competent adult (at least 18) at the home of, and living with the person in) ,or
Ban adult who seems to be in charge where the person in@) usually works, or
D1 Anadutt who seems to be in charge where the person in) usually receives mail, or has a private
post office box (not a U.S. Post Office box), if there is no known physical address for the person ind).
I told that adult, "Please give these court papers to (name of person int). "
I did this on (date): Co )- 29- / Lo At (time): RBZ Them Opa.
Atthisaddress: ~/O/] No eT Maa Isoas. Sty eat
City: Siock4ca) State: COO Zip: GSB6)
Name or description of the person I gave the papers to:
CA, AG-eVv
After serving the court papers, I put copies of the documents listed in (3) in an envelope, sealed the envelope,
and put first-class prepaid postage on it. | addressed the envelope to the person in @) at the address where I
left the copies.
* T mailed the envelope on (date)D) -36-Jka from (city, stacey: Lath yb i LA 9s SBey
by leaving it (check one):
al at a US. Postal Service mail drop, or
b.) Atan office or business mail drop where.Lknow the mail is picked up every day and deposited with the
US. Postal Service, or
c.L1 With someone else I asked to mail the documents to the person in @, and I have attached that person’s
completed Form SC-104A.
© Server's Information
Name: “JEFF MARQUIS ‘ Phone:__(209) 603-2223
Address: 477 EAST HEARTLAND
City: MANTECA
State:__CA __ Zip:_95337
Fee for service: $ _ 75.00
Ifyou are a registered process server:
County of registration: SAN JOAQUIN Registration number: PS-357
6) I deciare under penalty of perjury under California state Jaw that | am at least 18 years old and not named in this
case and that the information above is true and correct.
a lOn. sn
JEFF MARQUIS b Obes 7Torrpcees
Type or print server’s name Server signs here after s;
Revised vanuaey 1, 2000 Proof of Service SC-104, Page 2 of 2
(Small Claims)
Preview
Proof of Service , we cu rp I Sha Use this form to serve a person, a business, or a public entity. To leam more about proof of service, read What Is "Proof of Service"?, Form SC-104B. To learn more about how to serve a business or entity, read How to Serve a Business or Public Entity, Form SC-104C. To serve a business, you must serve one of the following people: * Owner (for a sole proprietorship) + Partner (for a partnership) or general partner (for a limited partnership) + Any officer or general manager (corporation or association) * Any person authorized for service by the business (corporation, association, general partnership, limited partnership) « Any person authorized for service with the Secretary of State (corporation, association, limited liability company [LLC], limited liability partnership [LLP], limited partnership) To serve a public entity, you must first file a claim with that entity, then serve one of the following people: * Clerk (of a city or county) * Chief officer or director (of a public agency) « Any person authorized for service by the entity @) “ME 1 are Sery) iat a person, write the person’s name below: lavcela 2. Buyciages b. If you are serving a business or entity, write the name of the business or entity, the person authorized for service, and that person’s job title: . f Business or Agency Name Person Authorized for Service Job Title @) Instructions to Server: 2OIGFEB £1 AM 10: 04 ROSA suspugga get Pury Fill in court name and street address: Superior Court of California, County of SAN JOAQUIN 222 EAST WEBER AVENUE STOCKTON.CALIFORNIA 95201 Fill in case number, case name, hearing date, day, time, and department below: Case Number: STK-CV-SC-2016- 0.00088. Case Name: Dameron Hospital Association, A Comp VS.Mavce/a A Buyeiago Hearing Date: 02-2 Q- 2 ol “| Time: \.30PM Dept: a eX You must be at least 18 years old and not be named in this case, Follow these steps: “» Give a copy of all the documents checked in @) to the person in @, or * Give a copy of all the documents checked in@) to one of the following people: a. A competent adult (at least 18) living with, and at the home of the person in ), OF b. An adult (at least 18) who seems to be in charge at the usual workplace of the person in @, or ¢. An adult (at least 18) who seems to be in charge where the person in @® usually receives mail {but not a U.S. Post Office box), if there is no known physical address for the person in@. and mail a copy of the documents left with one of the adults in a, b, or ¢ above to the person in). THEN + Complete and sign this form, and + Give or mail your completed form to the person who asked you to serve these court papers, in tine for the form to be filed with the court at least 5 days before the hearing. @) I served the person in @ a copy of the documents checked below: a. SC-100, Plaintiff's Claim and ORDER to Go to Small Claims Court b. O sc-120, Defendant's Claim and ORDER to Go to Small Claims Court hal) c. Order for examination (This form must be personally served. Check the form that was serve ed): Note: The court can issue a civil arrest warrant if the served party does not come to court only if the order for examination was personally served by a registered process server, sheriff, marshal, or Someone appointed by the court. *~ (1) C1 SC-134, Application and Order to Produce Statement of Assets and to Appear for Examination (2) EL] AT-138/EJ-125, Application and Order for Appearance and Examination d. OF Other (specify): Judicial Councal of Catfomnia, wawy.courinfo.ca gov Revised January 1, 2009, Optional Foam Code of Civil Procedure, §§ 116.340, 415.10, 415.20 Proof of Service (Smail Claims) “$C-104, Page 1 of 2 >a) We . Case Namber . soe . 2. Case name: Dameron Hospital Association Vs.Mavvela f, Buyciaq STK-CV-SC-2016- 20 8. (4) Fill out “a” or “b” below: a. [1] Personal Service: I personally gave copies of the documents checked in @) to the person in (4): On (date): * At (time): Olam. Opm. At this address: City: State: Zip: b. Substituted Service: | personally gave copies of the ddcuments checked in @) (a, b, or d) to (check one): (1A competent adult (at least 18) at the home of, and living with the person in) ,or Ban adult who seems to be in charge where the person in@) usually works, or D1 Anadutt who seems to be in charge where the person in) usually receives mail, or has a private post office box (not a U.S. Post Office box), if there is no known physical address for the person ind). I told that adult, "Please give these court papers to (name of person int). " I did this on (date): Co )- 29- / Lo At (time): RBZ Them Opa. Atthisaddress: ~/O/] No eT Maa Isoas. Sty eat City: Siock4ca) State: COO Zip: GSB6) Name or description of the person I gave the papers to: CA, AG-eVv After serving the court papers, I put copies of the documents listed in (3) in an envelope, sealed the envelope, and put first-class prepaid postage on it. | addressed the envelope to the person in @) at the address where I left the copies. * T mailed the envelope on (date)D) -36-Jka from (city, stacey: Lath yb i LA 9s SBey by leaving it (check one): al at a US. Postal Service mail drop, or b.) Atan office or business mail drop where.Lknow the mail is picked up every day and deposited with the US. Postal Service, or c.L1 With someone else I asked to mail the documents to the person in @, and I have attached that person’s completed Form SC-104A. © Server's Information Name: “JEFF MARQUIS ‘ Phone:__(209) 603-2223 Address: 477 EAST HEARTLAND City: MANTECA State:__CA __ Zip:_95337 Fee for service: $ _ 75.00 Ifyou are a registered process server: County of registration: SAN JOAQUIN Registration number: PS-357 6) I deciare under penalty of perjury under California state Jaw that | am at least 18 years old and not named in this case and that the information above is true and correct. a lOn. sn JEFF MARQUIS b Obes 7Torrpcees Type or print server’s name Server signs here after s; Revised vanuaey 1, 2000 Proof of Service SC-104, Page 2 of 2 (Small Claims)