Form 4-221A. Party's certificate of service.

[For use by parties in the Magistrate Courts] CERTIFICATE OF SERVICE I hereby certify that on this __________ day of ______________, __________ this _______________________ (insert paper served, such as "answer" or "notice") was [mailed by United States first class mail and addressed to] Name: __________________________________________________________________ Address: __________________________________________________________________ City, State __________________________________________________________________ and zip code: __________________________________________________________________ Telephone: __________________________________________________________________ [faxed by ________________________ (name of person who faxed document) to ______________________ (name of recipient) at _________________ (telephone number). The transmission was reported as complete. The time and date of the transmission was ________ [a.m.] [p.m.] on _____________________ (date).] [e-mailed to ______________________ (name of party or attorney) at _________________ (electronic mail address of recipient) upon agreement of the party to accept electronic service. The transmission was successful. The time and date of the transmission was _________ [a.m.] [p.m.] on _____________________ (date).] [delivered to __________________________ (Specify how service by delivery was made. See Use Note for the methods service may be made using this alternative.) ____________________________________.] ___________________________________________ Signature of person sending paper ___________________________________________ Date of signature