This government document is issued by Superior Court for use in California
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https://www.madera.courts.ca.gov/Images/MAD-0039%20Proof%20of%20Service%20-%20Petition%20for%20Relief%20Under%20Penal%20Code%20PC17(b),%2017(d)(2),%20PC1203.4,%20PC1203.4(a).doc