PROOF OF SERVICE OF STATEMENT OF AGREEMENT OR NONAGREEMENT
At the time of service, I was over 18 years of age and not a party to this action.
My residence or business address is:
I served the Statement of Agreement or Nonagreement (form ADR-100) on the person or persons below, as follows:
The form ADR-100 was served by the following means (check and complete all that apply):
Where personal service is indicated in item 4.b., I personally delivered the form ADR-100 to the persons for whom
personal service is indicated, at the addresses listed in item 4.c. (1) For a party represented by an attorney, delivery was
made to the attorney or at the attorney's office by leaving the document in an envelope or package clearly labeled to
identify the attorney being served with a receptionist or an individual in charge of the office, or in a visible location in the
office between the hours of 9 a.m. and 5 p.m. (2) For a party, delivery was made to the party or by leaving the document
at the party's residence with some person not younger than 18 years of age between the hours of 8 a.m. and 6 p.m.
The names, addresses, and other applicable information about persons served is on Attachment 4.
The fax number or electronic service address from which I served the document is (complete if service was by fax or
electronic service):
3.
4.
5.
a.
1.
2.
a. Name of person served
b. Manner of service
(specify personal, mail,
fax, or electronic)
c. Physical or mailing address,
fax number, or electronic service
address where person was served
d. Date
of service
e. Time
of service
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
Where service by mail is indicated in item 4.b., I enclosed the form ADR-100 in a sealed envelope or package
addressed to the persons at the addresses in item 4.c. and (specify one):
(1) deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid.
(2) placed the envelope for collection and mailing, following our ordinary business practices. I am readily familiar
with this business's practice for collecting and processing correspondence for mailing. On the same day that
correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the
United States Postal Service, in a sealed envelope with postage fully prepaid.
Where fax transmission is indicated in item 4.b., based on an agreement of the parties to accept service by fax
transmission, I faxed the form ADR-100 to the persons at the fax numbers listed in item 4.c. No error was reported by the
fax machine that I used. A copy of the record of the fax transmission, which I printed, is attached.
Where electronic service is indicated in item 4.b., I caused the form ADR-100 to be served on the persons at the
electronic service addresses listed in item 4.c., in accordance with a court order or an agreement of the parties allowing
electronic service.
I am a resident of or employed in the county where the mailing occurred. The envelope or package was placed in the mail at
(city and state):
c.
d.
b.
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STATEMENT OF AGREEMENT OR NONAGREEMENT
ADR-100 [Rev. July 1, 2012]
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