CV-21 (02/04) NOTICE AND ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT
UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
PLAINTIFF(S)
v.
DEFENDANT(S).
CASE NUMBER
NOTICE AND ACKNOWLEDGMENT OF
RECEIPT OF SUMMONS AND COMPLAINT
(For use with State Service only)
To:
The summons and complaint served herewith are being served pursuant to Rule 4(e)(1) of the Federal Rules of Civil
Procedure and Section 415.30 of the California Code of Civil Procedure.
You may complete the acknowledgment part of this form and return the completed form to the sender within twenty
(20) days.
If you are served on behalf of a corporation, unincorporated association including a partnership, or other entity, you
must indicate under your signature your relationship to that entity and your authorization to receive process for that
entity. If you are served on behalf of another person and you are authorized to receive process, you must indicate your
authority under your signature.
IF YOU DO NOT complete and return the form to the sender within twenty (20) days, you (or the party on whose
behalf you are being served), may be required to pay any expenses incurred in serving a summons and complaint in any
other manner permitted by law.
IF YOU DO complete and return this form, you (or the party on whose behalf you are being served), must answer the
complaint within the time provided in Rule 12 of the Federal Rules of Civil Procedure or judgment by default may be
taken against you for the relief demanded in the complaint.
I declare, under penalty of perjury, that this Notice and Acknowledgment of Receipt of Summons and Complaint was
mailed on .
Signature of Sender
ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT
(To be completed by recipient)
I declare under penalty of perjury, that I received a copy of the summons and complaint in the above-captioned matter at
on
Address Date
Signature
Relationship to Entity/Authority to Receive Service of Process
