I, ____________________________, of ______________________, ____________________,
(Print Name of Server) (Address) (City)
___________________, __________, ______-_______-______, certify that I am over the age
(State) (Zip) (Phone Number)
of 18 years old and that I am not a party to this case. I further certify that I served true copies of
this _________________ and _________________, dated ________,______, 20___, upon __________________.
(Name of Party Served)
Personally at: (Name and Address of Place Served) __________________________________
_____________________________________________________________________________
By Leaving copies thereof at the parties dwelling house or usual place of abode with a person of suitable age
and discretion then residing there. Name and age of person with whom the documents were left at: ______
_____________________________________________________________
By delivering a copy of the documents to an agent authorized by appointment of law to receive service of
process. Name of agent:_____________________________________
Date of Service was executed: __________________________
I declare under penalty of perjury that the foregoing information contained in the return of Service is true and
correct.
__________________________________
(Signature of Server)
