Free Summons Returned Executed - District Court of Connecticut - Connecticut

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, . ase 3:03-cv-00712-WWE Document 44 Filed O3/08/2004 Page 1 of 3 -
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UNITED STATES DISTRICT COURT
DISTRICT OF CONNECTICUT _
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GERTRUDE BAYONNE, 1 1 1 _1 1 1 1 11 11
US DIST E€{!£_i_ iQ¤,:t.i;~€2
Plaintiff(s), index NB.Rs1;Bt§Etiir2?yri‘2! rwlivs) 2
-against— AFFIDAVIT OF SERVICE
PITNEY BOWES INC., ET AL.,
Defendant(s).
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STATE OF NEW YORK ) l
S.S.: ,
COUNTY OF ROCKLAND ) 1
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DAVID KSIAZEK, being duly sworn, deposes and says that he is over the age of eighteen
years, is employed by the attorney service, D.L.S., INC., and is not a party to this action. 1
- That on the 4TH day of February, 2004, at approximately 2:35 PM, deponent served a true
copy of the SUMMONS, ORDER ON PRETRIAL DEADLINES, RULING ON REVISED MOTION
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TO AMEND AND REVISED AMENDED COMPLAINT upon PITNEY BOWES INC LONG TERM I
DISABILITY PLAN ADMINISTRATOR at l Elmcroft Road, Stamford, Connecticut 06926, by 1
personally delivering and leaving the same with JENNIFER SANDOBAL, who informed deponent that
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she is an legal assistant authorized by PITNEY BOWES INC LONG TERM DISABILITY PLAN
ADMINISTRATOR to receive service at that address.
JENNIFER SANDOBAL is a white female, approximately 26 years of age, stands
A 2
approximately 5 feet 6 inches tall, weighs approximately 150 pounds with brown hair and blue eyes.
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DAVID KSIAZE ##0974523
Sworn to before me this A 2 l _ U l ‘ ‘ s
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Qualified In Buckland County _ _ 2
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AO 440 (Rev. ‘l0i'93 m a Civil ___“_m_ _ \
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~ Qgmtzh States QBtstru:t (Huurt I
DISTRICT OF
CONNECTICUT _
GERTRUDE BAYONNE, K
Plalntlff SUMMONS IN A CIVIL CASE `
V- CASE NUMBER: 3:O3CVO71 2(NNE>
PITNEY BONES INC, S THE PITNEY
BONES INC LONG TERM DISABILITY PLAN,
THE PITNEY BONES INC LONG TERM DISABILITY
PLAN ADMINISTRATOR, THE PITNEY BONES INC
DISABILITY DEPARTMENT,
Defendants.
TOE {Name and address of defendant) 2
PITNEY BONES INC LONG TERM
DISABILITY PLAN ADMINISTRATOR
MSC O7—0O
One Elmcroft Road
Stamford, CT 06926
YOU ARE HEREBY SUMMONED and required to senre upon i=·l.AlNril=i=·s ATTORNEY mama and address}
Mark P. CArey y ‘
Carey & Associates PC
71 Old Post Road, Suite One
Southport, CT 06890
(ZOB) 255-4150
an answer to the complaint which is herewith served upon you, within 2 O days after service ofthis
summons upon you, exclusive ofthe day of service. If you fail to do so, judgment by default will be taken against youior the relief
demanded inthe complaint. You must also file your answer with the Clerk of this Coun within a reasonable period ot time after
service.
/éi9{pjf
CLERK DATE
0 . Warm
rev) DEPUTY CLERK
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~ , Case 3:03-cv-00712-WWE Document 44 Filed O3/08/2004 Page 3 of 3 \`~'
AO 4-40 {Rev. 10/93 Summons In a Clvll Action
" RETURN OF SERVICE
DATE
Service of the Summons and Complaint was made by me'
NAME OF SERVER (PRINT) TITLE .
Check one box below to indicate ap ropriate method of service y
lj Served personally upon the defendant. Piace 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: i
i
D Returned unexecuted: l

;
E
I] Other (specify): i



STATEMENT OF SERVICE FEES i
TRAVEL ‘ SERVICES TOTAL
- DECLARATION OF SERVER
l 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) Aa to who may serve e. summons see Flute 4 at the Federal Rules et Clvll Procedure. i
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