Judicial Council of California Form SC-104, Proof of Service (Small Claims) Completed Form Examples and Samples
View detailed examples and samples of a completed Judicial Council of California Form SC-104, Proof of Service (Small Claims). Learn how to correctly fill out and file the SC-104 form to prove you have legally served documents in your California small claims case.
Judicial Council of California Form SC-104, Proof of Service (Small Claims) Example
How this form was filled:
This example of a completed SC-104 form demonstrates how a friend of the plaintiff (the 'server') documents the personal service of a Plaintiff's Claim (SC-100) and other court documents on the defendant. The form details the server's identity, the person served, the date, time, and location of service, and a list of the documents that were delivered.
Information used to fill out the document:
- Plaintiff Name: Maria Garcia
- Defendant Name: John Smith
- Case Number: 26SC01234
- Court Name: Superior Court of California, County of Los Angeles
- Court Address: 111 North Hill Street, Los Angeles, CA 90012
- Server's Name: David Chen
- Server's Address: 789 Pine Street, Pasadena, CA 91101
- Service Method: Personal Service (Item 3a)
- Person Served: John Smith (Defendant)
- Date of Service: March 15, 2026
- Time of Service: 6:30 PM
- Address of Service: 456 Oak Ave, Los Angeles, CA 90012
- Documents Served: SC-100 (Plaintiff's Claim), SC-107 (Subpoena), and one attached local form
- Service Fee: $0.00
- Date of Signature: March 16, 2026
What this filled form sample shows:
- Correct completion of the case caption, including court name, parties, and case number.
- Clear indication of the service method, in this case, Personal Service (Item 3a).
- Precise details of the service, including the date, time, and location where the defendant was served.
- Accurate listing of all documents served on the defendant (Item 4).
- Properly filled server's declaration, confirming the server is over 18 and not a party to the case, signed and dated under penalty of perjury.
Form specifications and details:
| Form Name: | SC-104, Proof of Service (Small Claims) |
| Form Rev. Date: | January 1, 2024 |
| Jurisdiction: | Judicial Council of California |
| Use Case: | Filing proof of personal service by an individual (non-sheriff) in a small claims action. |
Created: February 02, 2026 11:05 PM
