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:
, I served the attached Replacement 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:
, California.
Type or print name
Signature _____________________________________________
Replacement panel represented 2014
click to sign
click to edit