Appendix H

THE CALIFORNIA STATE UNIVERSITY
PROOF OF SERVICE FORM – RECONSIDERATION PROCEDURE
UNIT 4

DIRECTIONS:

A copy of this form shall be appropriately filled out and attached to every filing or response to a request for reconsideration. Use Part 1 and Part 3 for delivery by mail. Use Part 2 and Part 3 for personal delivery.

PART 1:

Delivery by U.S. Mail: Proof of Service by Mail

I declare that I am over the age of eighteen years and not a party to the reconsideration request. My address is:

On _______________ (date) I served the attached reconsideration filing or response by placing a true copy enclosed in a sealed envelope with postage fully prepaid in the United States mail, addressed as follows:

PART 2:

Personal Delivery

I declare that on _______________ (date) I personally delivered the attached reconsideration request filing or response to:

Name of recipient: _______________________________ at

Location: _______________________________

PART 2:

I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed on:

_________________________ at__________________________ California
(Date) (City)

_________________________ __________________________
(Type or print name) (Signature)

(Revised 2001)