Bankruptcy Case No. Adversary Proceeding No.
CERTIFICATE OF SERVICE
, certify that I am, and at all times during the service of process was, not less than (name) 18 years of age and not a party to the matter concerning which service of process was made. I further certify that the service of this summons and a copy of the complaint was made by: (date) __ Mail service: Regular, first class United States mail, postage fully pre-paid, addressed to: I,
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Personal Service: By leaving the process with defendant or with an officer or agent of defendant at:
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Residence Service: By leaving the process with the following adult at:
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Certified Mail Service on an Insured Depository Institution: By sending the process by certified mail addressed to the following officer of the defendant at:
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Publication: The defendant was served as follows: [Describe briefly]
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State Law: The defendant was served pursuant to the laws of the State of as follows: [Describe briefly]
, (name of state)
Under penalty of perjury, I declare that the foregoing is true and correct. ___________________________________ Date __________________________________________ Signature
Print Name Jdkfljj _________________________________________________________________________ Business Address _________________________________________________________________________ City State Zip
[ver. 05/02]