Proof of Service PersonalCal. Super. - 6th Dist.May 11, 2020fl 0 _ ; Clerk stamps date here when form is filed. ‘30-1 04 Proof of Semce Use this form to serve a person, a business, or a public entity. To learn more F a L E about proof of service, read What Is ’TroofofService”?, Form SC-104B. To learn more about how to serve a business or entity, read How to Serve a Business 0r Public Entity, Form SC- 1 04C. To serve a business, you must serve one of the following people: Owner (for a sole proprietorship) Supeflor -.=- r . , o, 8am am Partner (for a partnership) or general partner (for a limited pannership) PINH V r Any officer or general manager (corporation or association) . . . . - - Fillinc rt ameadt tddres: ‘Any person authonzed for serv1ce by the busmess (corporatlon, assoc1at10n, o” n n s ree a S Superior Court of California, County ofi Any person authorized for service with the Secretary of State (corporation, 183;“?! CFlar: St t association, limited liability company [LLC], limited liability partnership ' "S ree [LLP], limited partnership) san Jose. 08- 951 1 3 To serve a public entity, you must first file a claim with that entity, then general partnership, limited partnership) serve one Of the fonowmg people: FiIl in case number, case name, hearing date, Clerk (0f a city or county) day, time, and department below: Chief officer or director (of a public agency) Case Number: Any person authorized for service by the entity 20$C083323 a. Ifyou are serving a person, write the person’s name below: Case Name: Karina Yavorkovsky Khan vs Yavorkovsky b. Ifyou 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: Hearing Date: 10/28/2020 Business or Agency Name Time: 8.30AM Dept: 1 5 Person Authorized for Service Job Title ® Instructions to Server: 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 CD , 0r Give a copy of all the documents checked in® to one ofthe following people: a. A competent adult (at least 18) living with, and at the home ofthe person in G) , 0r b. An adult (at least 18) who seems to b‘e in charge at the usual workplace of the person in CD , or c. An adult (at least 18) who seems to be in charge where the person in (1) 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 CD. 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 timefor theform to befiled with the court at least 5 days before the hearing.® I served the person in (D a copy of the documents checked below: a. E SC-100, Plaintifl’s Claim and ORDER to G0 t0 Small Claims Court b. D SC-120, Defendant’s Claim and ORDER t0 Go t0 Small Claims Court c. D 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 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) D SC-134, Application and Order to Produce Statement ofAssets and t0 Appearfor Examination (2) D AT-138/EJ-125, Application and Orderfor Appearance and Examination d. D Other (specz'fiz): ’ ° - _- - ' Cl‘ase’NumberB-JIV Case né'm'es ‘ :Q‘Khan vs,'Y_avo_rkovsky _ _ - I - ‘1 - _ _' _ _ U :»' .‘-2Q‘800333231A ' t G) Fill out “a” or “b” below: a. m Personal Service. Ipersonally gave copies of the documents checked 1n @_t'o t_he' person in G). On_ (date):- 10/7/2020. -' . ‘ At(time)- -5.2o___._I.D am m pm At this address- 20755 Scenic Vista Drive . _ I _ .Cityg' ' i- San Jose j I. ‘ _ : ':. A ’ - _- I .: :State. Ca:- - Zip .95120 b. D Substituted Service: I personally gave copies 'of the documents checked 1n. CD (a, b, 0r d) t_o (check one). D A competent adult (at__least 18) at the home of, and living with the person in (1) or D An adult who seems to be 1n charge where the person in-® usually Works, _or [:1 An adu_1t who seems to be 1n charge where the person in.@- usually receives mail, or has a. private_ post office box (not a U. S. P_ost Ofl'lce box), if there ls no known physical address for the person in ®. It_old that adult, "Please give these court papers to (name of person .in CD) " ’ Idid this on (date)._ I , ' - ‘ . - . - 7 At (time) r____D am. D pm. At this address: _ _ I _ . . ~ . ‘ > . 7 City: i > > 3 _ I , _ 1' _' i '7 - :4 ' _':Sta't:e:' l: ,- ':'Z_1p 1" ' i ‘ Name 01_" deScription 'of the'pe'réon' I gave the papers to:_ After serving the court papers, I put copies of the document's llsted-in® 1n an envelope, sealed the envelope, ~ and put- first-class prepaid postage on_ it. I addressed the envelope to the person in _®at- the address whereI left the copies. - - I-mailed the envelope on (date): - > ' : ' - from (city, state): - ' by leaving it (check one). ' a. D At a U. S. Postal Service mail drop, or b- D At an office or business mail drop where 'I know the m_ail ls picked up e__very 'day and deposited with theU._.S Postal Service, or c. D With someone else I asked to mail the documents to the person in@3 and I h‘ave attached that person’ s _completed Form SC-104A ' ‘ ® Servers Information Name_ Caneisha Howe_l| . 9 _ l' ' - I _ '_ - ‘ ”Pho-‘neif 4082282626 Address; P0‘BOX2113_7 ' _ _ V _v _ > A 3 I j > _ City; San JoSe v _. ' I - ' _ -‘ _ State; -=-C.a--_ zip; - 9’5109- _ ‘Fee.for service. $_ ' 37-50 ' Ifyou are a registeredprocess server County ofregi'stration: - ‘ ‘ ' , _ Registration number @. I declare under penalty of perjury under California: sta'te law that I am at least 18 years old and not named 1n this i case 'and that the information above 1s true and correct. ' Date: 10/07/2020 Caneisha-HoWell ' I .. , . - » v "g :\ ,V/ Type orprmt server s name : a Server szgfis’hereWer servmg' . RevisedJanuaryyzoos . ' Proof of Service ' ' . > , = -' ' ‘ . 'sc-104, Page 2 of 2 (Small Claims) ' j.-. ‘ Eo‘ridiiib‘n’ot‘e‘ctiafi afiagb‘rivac‘v.‘filéa§‘e-.bi駧 matelearg .
