Affidavit Of Service By Certified Mail

For Clerk's Use Only Name of Person Filing: ______________________________________ Mailing Address: ______________________________________ City, State, and Zip Code: ______________________________________ Daytime/Evening Phone: ______________________________________ ATLAS Number (if applicable):______________________________________ State Bar Number (if applicable):____________________________________ Representing: Self (No Attorney) Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number: _________________________ (Name of Applicant) AFFIDAVIT OF SERVICE BY BY CERTIFIED MAIL 1. I am familiar with the facts stated in this Affidavit, and I make this Affidavit to show that I have served copies of the "Application for change of Name" and the "Notice of Hearing Regarding Application for Change of Name" on the person named below by certified mail/restricted delivery, return receipt requested. Person served (name of other party): ___________________________________________________ Address where other party was served: _________________________________________________ Date of receipt by the other party: ____________________________________ 2. The Application and Notice listed above were received by the other party as shown by the receipt, the original of which is attached to this Affidavit on a separate piece of paper. OATH OR AFFIRMATION STATE OF ARIZONA ) )ss. COUNTY OF MOHAVE ) I affirm under penalty of perjury the information provided on this document is true and correct. Signature: ________________________________________ Date:______________________ Sworn to or affirmed before me on this ________________ day of _______________, 20________ By: ______________________________________ My Commission Expires: _____________________ _______________________________________ Notary Public or Deputy Clerk 1/4/2010 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com