[Your Name, & Address here]
[Recipient Name & address here]
’Personal Service Verification’
State of [State name], County of [County name]
I am [working/a resident of] the County of [county name], State of [state name], above the age of eighteen (18) years, and not a party to the within action; my [home/business] address is [write your home/business address].
The preceding documents, [title of documents] was/were served on the interested parties on [date] in this action by introducing a true [copy/copies] therein enclosed in an envelope addressed as follows:
I affected such envelope(s) to be delivered in person to the offices of the addressee(s).
Executed on [signed date] at [City, State].
I announce under the perjury penalty under the laws of the State of [state name] that the above said is true and correct.
[Person’s name effecting service]
Encl: [Enclosures List here]