Judicial Council of California Form SC-104, Proof of Service (Small Claims) Completed Form Examples and Samples

Find clear, filled-out examples of the Judicial Council of California Form SC-104, Proof of Service (Small Claims). Our samples demonstrate how to correctly document personal service and other methods, helping you properly file with the court.
Judicial Council of California Form SC-104, Proof of Service (Small Claims) has a moderate Form Complexity Index of 51/100 — Instafill’s AI completes it in under a minute.
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Completed California Form SC-104 Proof of Service for a small claims case demonstrating personal service.

Judicial Council of California Form SC-104 Example (Personal Service)

How this form was filled:

This example shows a completed Form SC-104 where a friend of the plaintiff personally served the defendant with small claims court papers. The form details the server's information, the date, time, and location of service, and lists the documents that were delivered.

Information used to fill out the document:

  • Server's Name: Jane Smith
  • Server's Address: 789 Neighbor St, Apt 2, Los Angeles, CA 90001
  • Server's Phone: (310) 555-0101
  • Court Name: Superior Court of California, County of Los Angeles
  • Court Address: 111 North Hill Street, Los Angeles, CA 90012
  • Case Number: 26SC01234
  • Plaintiff: Alex Johnson
  • Defendant: Michael Davis
  • Case Name: Alex Johnson v. Michael Davis
  • Service Type: Personal Service (Item 3a)
  • Person Served: Michael Davis
  • Date of Service: February 10, 2026
  • Time of Service: 6:15 PM
  • Address of Service: 456 Landlord Lane, Los Angeles, CA 90012
  • Documents Served: SC-100 (Plaintiff's Claim and Order to Go to Small Claims Court), and SC-107 (Small Claims Subpoena and Declaration).
  • Service Fee: $0.00
  • Date Signed: February 10, 2026

What this filled form sample shows:

  • Correctly identifies the court and case information at the top of the form.
  • Clearly indicates the server's name and address, confirming they are not a party to the lawsuit.
  • Specifies the exact date, time, and address of service.
  • Properly checks box 3a for Personal Service, showing the documents were handed directly to the defendant.
  • The server's declaration is accurately dated and signed under penalty of perjury.

Form specifications and details:

Form Name: SC-104, Proof of Service (Small Claims)
Jurisdiction: Judicial Council of California
Use Case: Proving personal service on an individual defendant in a small claims lawsuit.
Filing Requirement: Must be filed with the court clerk before the court date.
Categories: California judicial forms, Judicial Council forms, proof of service forms, small claims forms, VA claim forms
Created: February 03, 2026 06:06 AM
Completed California Form SC-104 Proof of Service for a small claims case demonstrating personal service.