am over the age of __________ (eighteen) years, and, on _______________ (date),
I mailed the ____________ (describe the paper or document mailed), a copy of
which is attached, to the addressee set forth below, by depositing a copy
enclosed in a postpaid wrapper, in an official depository under the exclusive
care and custody of the United States Postal Service, in __________ (city,
county, state), addressed as follows: _________________________________________________________________
(name and address of addressee).