UI / DE 400-B

SAMPLE, this page for reference only

NameBlank Space
ADJBlank Space

PROOF OF SERVICE BY MAIL

I,
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declare:
 I am over 18 years of age, and not a party to this action, and my business address is PO Box 2588, Rancho Cordova, California. On the date indicated below, following ordinary business practices, I placed for collection and mailing at the Employment Development Department (EDD), located at the above address, a copy of the attached
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in a sealed envelope, with postage fully prepaid, addressed to the following:
NameBlank Space
Address 1Blank Space
Address 2Blank Space
WORKERS' COMPENSATION APPEALS BOARD
EAMS
 I am readily familiar with the business's practice for collection and processing of correspondence for mailing with the United States Postal Service and, in the ordinary course of business, the correspondence would be deposited with the United States Postal Service on the day on which it is collected at the business.
 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date
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State of California, Employment Development Department (EDD)
EDD/IAD, MIC 24
PO Box 2588
Rancho Cordova CA 95741-2588
Telephone Number: ‎1-916-464-0713

DE 400-B Rev. 1 (5-22) (INTRANET)