AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2) Civil Action No. PROOF OF SERVICE (This section should not be 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) 0 I personally served the summons on the individual at on ; or (date) 0 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 on , and mailed a copy to the individual’s last address; or (date) 0 I served the summons on , who is (name of individual) designated by law to accept service of process on behalf of (name of organization) on ; or (date) 0 I returned the summons unexecuted because ; or 0 Other (specify): My fees are $ for travel and $ for services, for a total of $ . 0.00 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:
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2) Civil Action No. PROOF OF SERVICE (This section should not be 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) . 0 I personally served the summons on the individual at on (date) ; or 0 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 on (date) , and mailed a copy to the individual’s last address; or 0 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 0 I returned the summons unexecuted because ; or 0 Other (specify): My fees are $ for travel and $ for services, for a total of $ 0.00 . 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: