AO 440 (Rev 1/90) Summons in a Civil Action

RETURN OF SERVICE
Service of the Summons and Complaint was made by me1

DATE

NAME OF SERVER (PRINT)

TITLE

Check one box below to indicate appropriate method of service:

  • Served personally upon the defendant. Place where served: _________________________________
    ________________________________________________________________________________
  • Left copies thereof at the defendant’s dwelling house or usual place of abode with a person of suitable
    age and discretion then residing therein.
    Name of person with whom the summons and complaint were left: ___________________________
  • Returned unexecuted: ______________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________
  • Other (specify): ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________

STATEMENT OF SERVICE FEES
    TRAVEL     SERVICES     TOTAL

DECLARATION OF SERVER

I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct.

Executed on ______________________     ___________________________________
	            Date                        Signature of Server
 
                                       ___________________________________
                                               Address of Server




1) As to who may serve a summons, see Rule 4 of the Federal Rules of Civil Procedure.