Affidavit (Certificate) of Service Form

AFFIDAVIT OF SERVICE

County of [COUNTY]
State of [STATE]

Date: [DATE]

1. SERVER I, [SERVER NAME], declare under penalty of perjury that the following documents were delivered and served in the following manner:

2. DOCUMENTS. The documents served are described as: [DESCRIBE].

3. RECIPIENT. The above-mentioned documents were delivered to:

• Defendant/Respondent: [RECEIPIENT NAME]
• Address/Location: [ADDRESS]
• Date: [DATE], 20[YEAR] Time: [HOUR]:[MINUTE] ☐ AM ☐ PM

4. DELIVERY. The Recipient received the documents by: (check one)

☐ – Mail. The Server sent the documents in the mail by: (check all that apply)

☐ – Standard Mail
☐ – Electronic Mail (E-Mail)
☐ – Certified Mail (with return receipt)
☐ – FedEx
☐ – UPS
☐ – Other

☐ – Direct Service. The Server handed the documents to a person identified as the Recipient.

☐ – Someone at the Residence. The Server handed the documents to someone who identified as living at the residence and stated their name is: [NAME].

☐ – Someone at the Workplace. The Server handed the documents to someone who identified to be the Recipient’s co-worker and stated their name is: [NAME].

☐ – Leaving at the Residence. The Server left the documents in the following area: [AREA].

☐ – Recipient Rejected Delivery. The Server delivered the documents to the Recipient in-person and did not accept delivery.

☐ – Other. [DESCRIBE].

5. VERIFICATION. I declare under penalty of perjury under the laws located in this State that the foregoing is true and correct.

Server’s Signature: ________________________ Date: ______________

Print Name: ________________________