Proof of Service PersonalCal. Super. - 6th Dist.January 11, 2021_ Clerk stamps data here when form is filed. CH-200 Proof of Personal Servuce _ ® Person Seek'ng Protection €4ermm ‘9,ng ® Person From Whom Protection ls Sought Name; O bah; Raga s &OAZQJ@S © Notice to Server The server must: ' Be 18 years 0f age or older. o Not be listed in items® or® 0f Form CH-IOU. Fri! in court name and stree! address: Superior Court of California, County of Santa Clara 0 Give a copy of all documents checked in@ to the person in@. StreetAddress: 191 North First Street (You cannot send them by mail.) Then complete and sign [his Mailing Address: 191 NONh First Street form and give 0r mail it t0 the person in CD 33" Josev CA 951113 Civil Division PROOF OF PERSONAL SERVICE COU/T {IMS {n case number When form 1'5 filed. Case Number:@ I gave the person in®a copy 0f the forms checked below: 24c;Ago?6m a. M CH-109, Notice ofCourr Hearing b. m CH-l 10, Temporary Restraining Order c. m CH-IOO, Requestfor Civil Harassment Restraining Orders d. m CH-IZO, Response t0 Requestfor Civil Harassment Restraining Orders (blank form) . m CH-lZO-INFO, How Can 1 Respond t0 a Requestfor Civil Harassment Restraining Orders? D CH-IBO, Civil Harassment Restraining Order After Hearing . CH-BOO, ProofofFireanns Turned In, Sold, 0r Stored (blank form) . m Other (specifi): Dec]. Re: Notice Upon Ex Pane Application for orders for CiviI Harassment (CV-5014); I How Do l Turn ln or Sell My Firearms? (CH-BOQ-I F0); Local form FM-1047® I personally gave co 1es of the documents checked above to the person 1n : a. On(date): I I3 1M1) b. At(time).' H :50 Wam. me. c. Atthis address: 55-] Lexugs RA CitszgcaW‘I A1958, Ca ’ ' State: C9 ' Zip: 9.5" ll ® Server's Information Name: Z/Donch ”W: nfDHa vm Address: 2? g ' ”'1‘: S'H‘QQA‘ City: $01 V\ L’QS €- State: C9 Zip: 93’” Z Telephone: HQg AQS-H3Q O I ’01! (U'ea 7'8 [Sfel‘ed I‘OCGSS SBI'VEI‘ .‘g D‘G'Qr‘hfb County of registration: Re ' xon umber: I declare under penalty 0f perjury under the laws ofthe State of lifomia l at the informatiop above is true and correct. g Date:///3/QOQI /'/ ) W /W ¥ Type or print .ren'er': name /ServerKama here f V JUdJcialCouncfl ol'Cafifornia. www.courfacagov PrOOf Of Personal serVice CH-200, Page 1. 0f 1 Rovlsed July 1, 2014. Optional Form . . oodeoxcavnpmcedure.§527.s (Ciwl Harassment Prevention)