Fillable Proof of Service By Mail I am a (California)

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Proof of Service By Mail I am a (California)

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Proof of Service By Mail
I declare that:
I am a resident of or employed in the county where the mailing took place. I am over the age of eighteen
years, my business or residence address is:
On
, I served the attached Additional Panel Order the in said case, by placing a true copy thereof
enclosed in a sealed envelope with postage thereon fully paid, in the United States mail, addressed as follows:
Division of Workers' Compensation-Medical Unit
P.O. Box 71010
Oakland, CA 94612
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct,
and that this declaration was executed on:
Date: at
, California.
City
Type or print name
Signature _____________________________________________
Order Additional Panel QME-Represented-2014
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Proof of Service By Mail I am a (California)

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Completed 18 March 2021

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