Preview
-*
v
lena Tt) Proof of Service
Use this form to serve a person, a business, or a public entity. To learn 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
@) a. Ifyou are serving a person, write the person’s name below:
MARY DELAROSA
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:
Business or Agency Name
Person Authorized for Service Job Title
@) Instructions to Server: :
Clerk stamps date here IL
Prope
SUPERIOR Cour T
“OPH hs 1
“ $8 SUNY;
— E| LEH
OPSUFY —
jen form is filed.
2008 MAR
Fill in court name and street address:
Superlor Court of California, County of
SAN JOAQUIN
180 EAST WEBER AVENUE
SUITE # 200
STOCKTON CALIFORNIA 95202
Civil _/ Small ‘Claims Division
Fill in case number, case name, hearing date,
day, time, and department below:
Case Number:
STK-CV-SC-2020-0002258
Case Name: :
Dameron Hospital Association, A
Corp. Vs MARY DELAROSA
Hearing Date: 03/23/2020
Time:
9:00AM jDept: D-6
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 @, or
b. An adult (at least 18) who seems to be in charge at the usual workplace of the person in ®, or
c. 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 c 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 time for
the form to be filed with the court at least 5 days before the hearing.
a SC-100, Plaintiff's Claim and ORDER to Go to Small Claims Court
@) I served the person in @ a copy of the documents checked below: : ) OQ
b. 0 sc-120, Defendant's Claim and ORDER to Go to Small Claims Court
c. L] Order for examination (This form must be personally served. Check the. form that was served):
Note: The court can issue a civil arrest warrant if the served party does not comé to court only if the order for
examination was personally served by a registered process server, sheriff, marshal, or someone appointed by the court.
() C0 sc-134, Application and Order to Produce Statement of Assets and to Appear for Examination
(2) 2) AT-138/EJ-125, Application and Order for Appearance and Examination
d. (1 Other (specify):
Judicial Counc! of Calfomia, www. courtinfo.co.gov
Revised January 1, 2009, Optional Form
Code of Civil Procedure, §§ 116.340, 416.10, 416.20
Proof of Service
(Small Claims)
SC-104, Page 1 of 2
>a
Case Number:
Case name: Dameron Hospital Association Vs. MARY DELAROSA STK-CV-SC-2020-0002258
(4) Fill out “a” or “b” below:
a. Personal Service: I personally gave copies of the documents checked in ® to the person in @):
On (date): 03/03/2020___At (time): _10:33 am, pm.
‘Atthis address: __1971 PASSAGES STREET
City; _ MANTECA State:__CA__ zip, 95336
b. (1 Substituted Service: I personally gave copies of the documents checked in ® (a, 6, or d) to (check one):
( Acompetent adult (at least 18) at the home of, and living with the person in@) ,or
(J An adult who seems to be in charge where the person in@) usually works, or
DC Anadult 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 in@)."
I did this on (date): At (time): Oam. O pm.
At this address:
City: State: Zip:
Name or description of the person I gave the papers to:
After serving the court papers, I put copies of the documents listed in @ in an envelope, sealed the envelope,
and put first-class prepaid postage on it. I addressed the envelope to the person in @ at the address where I
left the copies.
I mailed the envelope on (date): from (city, state):
by leaving it (check one):
a. AtaU.S. Postal Service mail drop, or
b.C) Atan office or business mail drop where I know the mail is picked up every day and deposited with the
US. Postal Service, or :
ce. With someone else I asked to mail the documents to the person in (4), and I have attached that person’s
completed Form SC-104A.
® Server's Information
Name: JEFF MARQUIS Phone:__(209) 603-2223
Address: 477 HEARTLAND DRIVE
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
I declare under penalty of perjury under California state law that I am at least 18 years old and not named in this
case and that the information above is true and correct,
Date: 3-3-2026 .
JEFF MARQUIS > olow WMprgrsll
Type or print server's name Server sighs Were after serving”
Revised January 1, 2009 Proof of Service SC-104, Page 2 of 2
(Small Claims)
Preview
-* v lena Tt) Proof of Service Use this form to serve a person, a business, or a public entity. To learn 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 @) a. Ifyou are serving a person, write the person’s name below: MARY DELAROSA 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: Business or Agency Name Person Authorized for Service Job Title @) Instructions to Server: : Clerk stamps date here IL Prope SUPERIOR Cour T “OPH hs 1 “ $8 SUNY; — E| LEH OPSUFY — jen form is filed. 2008 MAR Fill in court name and street address: Superlor Court of California, County of SAN JOAQUIN 180 EAST WEBER AVENUE SUITE # 200 STOCKTON CALIFORNIA 95202 Civil _/ Small ‘Claims Division Fill in case number, case name, hearing date, day, time, and department below: Case Number: STK-CV-SC-2020-0002258 Case Name: : Dameron Hospital Association, A Corp. Vs MARY DELAROSA Hearing Date: 03/23/2020 Time: 9:00AM jDept: D-6 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 @, or b. An adult (at least 18) who seems to be in charge at the usual workplace of the person in ®, or c. 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 c 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 time for the form to be filed with the court at least 5 days before the hearing. a SC-100, Plaintiff's Claim and ORDER to Go to Small Claims Court @) I served the person in @ a copy of the documents checked below: : ) OQ b. 0 sc-120, Defendant's Claim and ORDER to Go to Small Claims Court c. L] Order for examination (This form must be personally served. Check the. form that was served): Note: The court can issue a civil arrest warrant if the served party does not comé to court only if the order for examination was personally served by a registered process server, sheriff, marshal, or someone appointed by the court. () C0 sc-134, Application and Order to Produce Statement of Assets and to Appear for Examination (2) 2) AT-138/EJ-125, Application and Order for Appearance and Examination d. (1 Other (specify): Judicial Counc! of Calfomia, www. courtinfo.co.gov Revised January 1, 2009, Optional Form Code of Civil Procedure, §§ 116.340, 416.10, 416.20 Proof of Service (Small Claims) SC-104, Page 1 of 2 >a Case Number: Case name: Dameron Hospital Association Vs. MARY DELAROSA STK-CV-SC-2020-0002258 (4) Fill out “a” or “b” below: a. Personal Service: I personally gave copies of the documents checked in ® to the person in @): On (date): 03/03/2020___At (time): _10:33 am, pm. ‘Atthis address: __1971 PASSAGES STREET City; _ MANTECA State:__CA__ zip, 95336 b. (1 Substituted Service: I personally gave copies of the documents checked in ® (a, 6, or d) to (check one): ( Acompetent adult (at least 18) at the home of, and living with the person in@) ,or (J An adult who seems to be in charge where the person in@) usually works, or DC Anadult 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 in@)." I did this on (date): At (time): Oam. O pm. At this address: City: State: Zip: Name or description of the person I gave the papers to: After serving the court papers, I put copies of the documents listed in @ in an envelope, sealed the envelope, and put first-class prepaid postage on it. I addressed the envelope to the person in @ at the address where I left the copies. I mailed the envelope on (date): from (city, state): by leaving it (check one): a. AtaU.S. Postal Service mail drop, or b.C) Atan office or business mail drop where I know the mail is picked up every day and deposited with the US. Postal Service, or : ce. With someone else I asked to mail the documents to the person in (4), and I have attached that person’s completed Form SC-104A. ® Server's Information Name: JEFF MARQUIS Phone:__(209) 603-2223 Address: 477 HEARTLAND DRIVE 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 I declare under penalty of perjury under California state law that I am at least 18 years old and not named in this case and that the information above is true and correct, Date: 3-3-2026 . JEFF MARQUIS > olow WMprgrsll Type or print server's name Server sighs Were after serving” Revised January 1, 2009 Proof of Service SC-104, Page 2 of 2 (Small Claims)