Free Summons in a Social Security Case (WVSD Local Form) - West Virginia

AO 440 (Rev. 01/09) Summons in a Social Security Case

UNITED STATES DISTRICT COURT
for the

Southern District of West Virginia
) ) ) ) )

Plaintiff

v.
MICHAEL J. ASTRUE, Commissioner of Social Security
Defendant

Civil Action No.

SUMMONS IN A SOCIAL SECURITY CASE To: (Defendant's name and address)
COMMISSIONER OF SOCIAL SECURITY 6401 Security Boulevard Baltimore, Maryland 21235 (1 copy)
ATTORNEY GENERAL OF THE UNITED STATES United States Department of Justice 950 Pennsylvania Avenue, NW Washington, DC 20530 (1 copy)

UNITED STATES ATTORNEY FOR THE SOUTHERN DISTRICT OF WV Post Office Box 1713 Charleston, WV 25326 (1 copy)

A lawsuit has been filed against you. Within 60 days after service of this summons on you (not counting the day you received it), you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff's attorney, whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. You also must file your answer or motion with the court.

CLERK OF COURT

Date:
Signature of Clerk or Deputy Clerk

AO 440 (Rev. 01/09) Summons in a Social Security Case (Page 2)

Civil Action No. PROOF OF SERVICE (This section should not be filed with the court unless required by Fed. R. Civ. P. 45.) This summons for (name of individual and title, if any) was received by me on (date) .

' I personally served the summons on the individual at (place) on (date) ' I left the summons at the individual's residence or usual place of abode with (name) , a person of suitable age and discretion who resides there, on (date) , and mailed a copy to the individual's last known address; or , who is on (date) ' I returned the summons unexecuted because ' Other (specify): . My fees are $ for travel and $ for services, for a total of $ . ; or ; or ; or

' I served the summons on (name of individual) designated by law to accept service of process on behalf of (name of organization)

0.00

I declare under penalty of perjury that this information is true.

Date:
Server's signature

Printed name and title

Server's address

Additional information regarding attempted service, etc:

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