Case 1:17-cv-00616-JGK Document 9 Filed 01/27/17 Page 2 of 2

Case 1:17-cv-00616-JGK Document 9 Filed 01/27/17 Page 2 of 2 AL) 440 (Rqv. Oh 11) Summtm, m a Coll Acta (Pave 21 Civil Action No. PROOF OF SERVICE (This section should not be ad with the court unless required by Fed. R. Civ. P. 4 (I)) This summons for (name of individual and title. lamp was received by me on Nate/ O I personally served the summons on the individual at (place) on Nato : or O I left the summons at the individual's residence or usual place of abode with Mantel , a person of suitable age and discretion who resides there. on Nato , and mailed a copy to the individual's last known address; or Date: O I served the summons on (Mime of individual) designated by law to accept service of process on behalf of /name orgarnzariewil on Nato ; or O I returned the summons unexecuted because O Other OPeribl: My fees are S who is for travel and S for services, for a total of S _ 0.00 I declare under penalty of perjury that this information is true. Additional information regarding attempted service. etc Print Save As... Server .1? vigmeure Printed name urns! ode SMIrt ;or Reset EFTA00313631