(State your name and address): □ Plaintiff □ Defendant
Telephone No.: Fax No. (Optional):
E-Mail Address (Optional):
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE
JUSTICE CENTER:
□ Central - 700 Civic Center Dr. West, Santa Ana, CA 92701-4045
□ Harbor - Newport Beach Facility - 4601 Jamboree Rd., Newport Beach CA, 92660-2595
□ North - 1275 N. Berkeley Ave., P. O. Box 5000, Fullerton, CA 92838-0500
□ West - 8141 13
th
Street, Westminster, CA 92683-4593
PLAINTIFF:
DEFENDANT:
CERTIFIED MAIL STATEMENT
(SMALL CLAIMS)
CASE NUMBER:
For a fee, the clerk will attempt to serve your claim by certified mail with return receipt requested. This is considered
the least reliable method of service because the addressee can refuse or not be available to sign the postal receipt. If
the person you are suing or the person’s agent for service doesn’t sign the U.S. Postal mail receipt with his or her
complete name, or if someone else signs the receipt, you will have to serve again using personal or substituted
service.
The court may not hear your case if:
• The certified mail is returned as unclaimed or refused by addressee or undeliverable as addressed.
• The Postal Service has not returned a signed receipt or the certified letter before the court date.
• The certified letter is not addressed to the proper party to be served.
• The return receipt is signed outside California, except for the owner of record of real property in California who
resides in another state.
• The return receipt mail is sent by someone other than the clerk of the Small Claims Division.
• The return receipt is signed by someone other than the addressee, unless the party appears and waives
service.
Your case may be dismissed on the date set for trial if proper service has not been completed (Rule 343 of the Local
Rules – Superior Court of California, County of Orange).
The court will not notify you if the claim has or has not been served. To find out if the certified mail return receipt has
been signed you may call the Small Claims Office. Please wait 20 days before calling.
The clerk will attempt delivery of your claim as addressed on the claim (unless a different address is specified below).
If service will be for a partnership or corporation, complete the following information:
Name of officer, authorized agent, or partner:
Title of party listed above:
Address (if different from claim):
I have read the above information and request the clerk attempt delivery of my claim.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF PLAINTIFF OR DEFENDANT)
Approved for Optional Use
L-1091 (Rev. July 2013)
CERTIFIED MAIL STATEMENT
(SMALL CLAIMS)
Code of Civil Procedure,
§ 116.340(a)(1)
For your protection and privacy, please press the Clear
This Form button after you are done printing the form.
