Proof of Service PersonalCal. Super. - 6th Dist.January 4, 2021O1 , @® ,_1 flw, Clerk stamps dare here when form is filed, Proof of Personal Service Person Seeking ProtectionNmmwcha woc‘bwomy F I L E nPerson From Whom Protection ls Sought . , N l Name; vmcgl EDWARD ORoé 49 1 202' Notice to Server K _ C'e the Court z-A) 'r \ BY a m The server must: Q :3 27,27 l~ ' BC 18 years Ofage 0r Older- /k\a\ ask fekr/R Fill in court name am: street address. o Not be listed in items CD or© § )' l _ / \%%/ I Superior Court of California, County of ofForm CH-loo. F‘» ’ / “Xx 17 SamaCIara 191 N. First St. ° Give a copy ofall documents checked in@ to the person in®. San Jose CA 951 13 (You cannot send them by mail.) Then complete and sign this form and give or mail it to the person in CD. PROOF OF PERSONAL SERVICE I cave the person in®a copy ofthe forms checked below' case Number: Q 9= ' $1: QH 00 7 5 a. E CH- 1 O9, Notice ofCourt Hgarz‘ng b. E CH-l 10, Temporary Restraining Order c. E CH- l 00, Requeslfor Civil Harassment Restraining Orders d. E CH- l 20, Response r0 Requestfor Civil Harassment Restraining Orders (blank form) e. E CH- l 20-INFO, Hon" Can I Respond Io a chucstfor Civil Harassment Restraining Orders? f. D CH- 1 30, Civil Harassment Rcslraining Order Afrer Hearing g. E CH-SOO, ProqfofFirearms Turned In, Sold, 0r Stored (blank form) h. E Other (Specify): Dccl. CV-5014 and Civil Case Cover Sheet CM-OIO I personally gave copies oflhe documents checked above to the person i @2 a. On (dale): 0 - ., ‘ b. At (lime)? H .' 50 a.m. D p.m. C- A‘ this address "IOTtK HOME) C3954 LomA €04} , H/A/ £61“ I 7' o oa-L City: Ina,{‘[a‘,,4cv H/Lg. State: I&A Zip: 95 [4’0 Server's Information Name: Awtw éMd 1A Address: 302-39 (c MEL (hd‘J-M‘ 16‘ City: £05 j‘dcj State: (A Zip; ‘15033 Telephone: flB/ “ 3‘]?~ H I 76 (Ifyou are a registered process server): County ofregistration: NZI-L Registration number: N [Q I declare under penalty ofperjury under the laws ofthe State ofCalifomia that the information above is true and correct. Date: I] IO [262I l’) /" A. .0 us-hvx 5mw } /T5 Type 0r prim sen er '5 name Sen 6r Io sign here J dI |C l 'Call . " . _ Ruev‘csxzd Jinn? Zocu‘looplwloialvavziour‘s ca ,ov Proof of Personal Serv'ce CH 200, Page 1 Of1 C°“°°‘°V"P'°“°“'e 55275 (Civil Harassment Prevention)
