I agree I received the following:
NOTICE AND ACKNOWLEDGMENT OF RECEIPT
(Family Law)
Form Approved for Optional Use
Judicial Council of California
FL-117 [Rev. January 1, 2015]
FL-117
a.
b.
c.
Page 1 of 1
Code of Civil Procedure, § 415.30, 417.10
www.courts.ca.gov
NOTICE AND ACKNOWLEDGMENT OF RECEIPT
FOR COURT USE ONLY
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
PETITIONER:
RESPONDENT:
CASE NUMBER:
Family Law: Petition—Marriage/Domestic Partnership (form FL-100), Summons (form FL-110), and blank Response—
Marriage/Domestic Partnership (form FL-120)
Uniform Parentage: Petition to Establish Parental Relationship (form FL-200), Summons (form FL-210), and blank
Response to Petition to Establish Parental Relationship (form FL-220)
Custody and Support: Petition for Custody and Support of Minor Children (form FL-260), Summons (form FL-210), and
blank Response to Petition for Custody and Support of Minor Children (form FL-270)
ACKNOWLEDGMENT OF RECEIPT
NOTICE
The documents identified below are being served on you by mail with this acknowledgment form. You must personally sign, or a
person authorized by you must sign, this form to acknowledge receipt of the documents.
If the documents described below include a summons and you fail to complete and return this acknowledgment form to the sender
within 20 days of the date of mailing, you will be liable for the reasonable expenses incurred after that date in serving you or
attempting to serve you with these documents by any other methods permitted by law. If you return this form to the sender, service
of a summons is deemed complete on the date you sign the acknowledgment of receipt below. This is not an answer to the action.
If you do not agree with what is being requested, you must submit a completed Response form to the court within 30 calendar days.
To (name of individual being served):
Recipient signed this acknowledgment on (specify date):
Date of mailing (specify):
(TYPE OR PRINT SENDER'S NAME)
(SIGNATURE OF SENDER—MUST NOT BE A PARTY IN THIS CASE
AND MUST BE 18 YEARS OR OLDER)
(SIGNATURE OF PERSON ACKNOWLEDGING RECEIPT)
(TYPE OR PRINT NAME OF PERSON ACKNOWLEDGING RECEIPT)
(1)
(2)
(3)
(7)
(4)
d.
(8)
Completed and blank Declaration Under Uniform
Child Custody Jurisdiction and Enforcement Act
(form FL-105)
Completed and blank Declaration of Disclosure
(form FL-140)
Completed and blank Schedule of Assets and
Debts (form FL-142)
Completed and blank Property Declaration (form
FL-160)
Request for Order (form FL-300), and blank
Responsive Declaration to Request for Order
(form FL-320)
Other (specify):
(6)
Completed and blank Financial Statement
(Simplified) (form FL-155)
Completed and blank Income and Expense
Declaration (form FL-150)
(5)
4.
2.
1.
3.
5.
6.
(Sender completes items 1 through 4 and signs before mailing. Recipient completes items 5 and 6, signs, then returns)
For your protection and privacy, please press the Clear
This Form button after you have printed the form.
JOHN SMITH
1 PENNY LANE
WALNUT CREEK, CA 94596
