Free UNITED STATES DISTRICT COURT - Missouri

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MISSOURI

NOTICE AND ACKNOWLEDGMENT FOR SERVICE BY MAIL
_________________________ vs. _________________________ CASE NUMBER:_____________________

NOTICE
TO:_____________________________________________________________________
Name and Address of Person to be Served This form is to be used only when service of a complaint is being made by mail. The enclosed summons and complaint are served pursuant to Rule 4 of the Federal Rules of Civil Procedure and Rule 54.16 of the Missouri Supreme Court Rules. You may sign and date the acknowledgment below and return one copy of the completed form to the sender to be received by the sender within 30 days of the date of the mailing indicated below. If you are served on behalf of a corporation, unincorporated association (including partnership), or other entity, you must indicate under your signature your relationship to that entity. If you are served on behalf of another person and you are authorized to receive process, you must indicate under your signature your authority. If you do not complete and return the form to the sender within the period indicated above, you (or the party on whose behalf you are being served) may be required to pay any expenses incurred in serving the summons and complaint in any other manner permitted by law. THIS FORM IS NOT AN ANSWER TO THE COMPLAINT. If you complete and return this form, you or the party on whose behalf you are being served must answer the complaint within twenty days of the date you sign the acknowledgement below. If you fail to do so, judgment by default may be taken against you for the relief demanded in the complaint. I declare under penalty of perjury that this Notice and Acknowledgment For Service By Mail was mailed on ______________________. Date ___________________________ Signature of Sender ___________________________ Name of Sender ______________________________ Address of Sender

ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT
I declare, under penalty of filing a false affidavit, that I received a copy of the summons and the complaint in the above captioned matter. _______________________________________ Signature _____________________________________________________ Relationship to Entity or Authority to Receive Service of Process

_____________________________________
Date Signed