Form App 109 – Fill Out and Use This PDF

You fill in the name and street address of the court that issued the decision that is being challenged in this case: Superior Court of California, County of.

You fill in the number and name of the trial court case in which the decision being challenged was issued: Trial Court Case Number and Trial Court Case Name.

You fill in the appellate division case number (if you know it): Appellate Division Case Number.

At the time I served the documents listed in , I was at least 18 years old.

I am not a party in the case identified in the box on the right side of the page.

My home business address is: Street City State Zip.

I mailed or personally delivered the following document, (check or fill in the name of the document you are serving and check and complete either a or b).

The documents listed are Notice of Appeal/Cross Appeal (Limited Civil Case), Notice Designating Record on Appeal (Limited Civil Case), Proposed Statement on Appeal (Limited Civil Case, Misdemeanor, Infraction), Appellant's Opening Brief, Respondent's Brief, Appellant's Reply Brief, Abandonment of Appeal (Limited Civil Case), Petition for Writ (Misdemeanor, Infraction, or Limited Civil Case), and Other (write in the name of the document).

Service by Mail: I put one copy of the document identified in in an envelope addressed to each person listed in (2), sealed the envelope, and put first-class postage on the envelope.

The envelope or envelopes were addressed as follows: Name of person served; Address on envelope: Street City State Zip.

Check here if you mailed copies of the document identified in to more people. Attach a separate page listing the names and addresses on each additional envelope you mailed. Write “APP-109, Item 4a” on the top of the page.

I mailed the envelope or envelopes on (date) from (city) (state) by depositing the envelope or envelopes (check one): With the U.S. Postal Service or At an office or business mail drop where I know the mail is picked up every day and deposited with the U.S. Postal Service.

Service by Personal Delivery: I personally gave one copy of the document identified in to each of the following people:

For each person, enter Name of person served, Address where you gave the documents to this person: Street City State Zip, Date when you gave the documents to this person, and Time when you gave the documents to this person.

Check here if you gave copies of the document identified in to more people. Attach a separate page listing the names of each of these people, the address where you gave each of them the document, and the date and time you gave them the document. Write “APP-109, Item 4b” on the top of the page.

5 I declare under penalty of perjury under California state law that the information is true and correct.

This form is only for providing proof that a document has been served (delivered) in a proceeding in the superior court appellate division. If you are serving a document electronically, please use Proof of Electronic Service (Appellate Division) (form APP-109E).