Certificate Of Service {SCA-FC-314}

CERTIFICATE OF SERVICE State of West Virginia County of _______________________________ I, _______________________, mailed ________________________________________ (Print your name.) (List the items you mailed.) __________________________________________________________, by first class mail, to: __________________________________________________________________________; and (Print name and address of person you mailed the items to.) _____________________________________________________________________________, (Print name and address of person you mailed the items to.) on the ____ day of __________________, _____. ___________________________ ____________ Signature Date SCA-FC-314 (12/01) Certificate of Service Page 1 of 1