Free 58 - New York

CIVIL COURT OF THE CITY OF NEW YORK County of ___________________ ________________________________________

Index Number _______________ Affidavit of Service of Restraining Notice ____________________________
Judgment Debtor's Name

Claimant/Plaintiff, -against-

____________________________
Address

Defendant. ________________________________________ State of New York, County of _______________ ss.:

____________________________
City , State, Zip

. _____________________________________, being duly sworn, deposes and says:
Name of Deponent

I am over the age of 18 and not a party to this action. At ________________, on ________________________, Time
Date

I served the following papers: check the box next to the title(s) papers served ~ A. Restraining Notice; ~ B. Restraining Notice and Notice to Judgment Debtor, or ~ C. Restraining Notice, Exemption Notice and two Exemption Claim forms with sections titled "Address A" and "Address B" filled out, on ______________________________________________________________________________ G by mailing the papers in an envelope addressed to _________________________________________________________________________ by Certified Mail Return Receipt Requested. OR G by delivering papers to ______________________________________________________ at the following address: _____________________________________________________. _____________________________
Signature of Server

Sworn to before me this ______ day of ______________, 20 ___ ____________________________________ Signature of Notary
CIV-SC-58 (Revised 1/09)

FREE CIVIL COURT No fee may be charged to fill in this form. Form can be found at: http://www.nycourts.gov/courts/nyc/smallclaims/forms.shtml