PROOF OF SERVICE / CERTIFICATE OF DELIVERY AFFIDAVIT
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Effective Date: ________________________________________________________
Place: _________________________________________________________________

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1. Signatory
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This document is made on ____________________ (____________________) by:

Person Who Served the Documents
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
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2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
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Document(s) Served: ____________________________________________________
Person Served: _________________________________________________________
Date & Time of Service: ________________________________________________
Place of Service: ______________________________________________________
Method of Service: _____________________________________________________

3. EXECUTION & SIGNATURES
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Person Who Served the Documents

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________