AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)
Civil Action No.
PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))
This summons for
(name of individual and title, if any)
was received by me on (date) .
’ I personally served the summons on the individual at
(place)
on (date) ; or
’ I left the summons at the individual’s residence or usual place of abode with
(name)
, a person of suitable age and discretion who resides there,
on
(date) , and mailed a copy to the individual’s last known address; or
’ I served the summons on
(name of individual) , who is
designated by law to accept service of process on behalf of
(name of organization)
on (date) ; or
’ I returned the summons unexecuted because ; or
’ Other
(specify):
.
My fees are $ for travel and $ for services, for a total of $ .
I declare under penalty of perjury that this information is true.
Date:
Server’s signature
Printed name and title
Server’s address
Additional information regarding attempted service, etc: