Statement of Service by Mail and
Acknowledgement of Receipt by Mail of
Summons and Complaint or Summons and Notice or Notice of Petition and Petition
A. STATEMENT OF SERVICE BY MAIL
To: (Insert the name and address of the person or entity to be served.) The enclosed summons and complaint, or summons and notice, or notice of petition and petition (strike out inapplicable terms) are served pursuant to section 312-a of the Civil Practice Law and Rules.
To avoid being charged with the expense of service upon you, you must sign, date and complete the acknowledgement part of this form and mail or deliver one copy of the completed form to the sender within thirty (30) days from the date you receive it. You should keep a copy for your records or your attorney. If you wish to consult an attorney, you should do so as soon as possible before the thirty (30) days expire.
If you do not complete and return the form to the sender within thirty (30) days, you (or the party on whose behalf you are being served) will be required to pay expenses incurred in serving the summons and complaint, or summons and notice, or notice of petition and petition in any other manner permitted by law, and the cost of such service as permitted by law will be entered as a judgment against you.
If you have received a complaint or petition with this statement, the return of this statement and acknowledgement does not relieve you of the necessity to answer the complaint or petition. The time to answer expires twenty (20) days after the day you mail or deliver this form to the sender. If you wish to consult with an attorney, you should do so as soon as possible before the twenty (20) days expire.
If you are served on behalf of a corporation, unincorporated association, partnership or other entity, you must indicate under your signature your relationship to the 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.
It is a crime to forge a signature or to make a false entry on this statement or on the acknowledgement.
B. ACKNOWLEDGEMENT OF RECEIPT OF SUMMONS AND COMPLAINT OR SUMMONS AND NOTICE OR NOTICE OF PETITION AND PETITION
I received a summons and complaint, or summons and notice, or notice of petition and petition (strike out inapplicable terms) in the above-captioned matter at (insert address).
PLEASE CHECK ONE OF THE FOLLOWING;
IF 2 IS CHECKED, COMPLETE AS INDICATED:
1. / / I am not in military service.
2. / / I am in military service, and my rank and branch of service are as follows:
Rank:___________________________________
Branch of Service:______________________
TO BE COMPLETED REGARDLESS OF MILITARY STATUS:
Date:_____________________________________________
(Date this Acknowledgement is executed)
I affirm the above as true under penalty of perjury.
__________________________________
Signature
__________________________________
Print name
__________________________________
Name of Defendant for which acting
__________________________________
Position with Defendant for which acting (i.e., officer, attorney, etc.)
PLEASE COMPLETE ALL BLANKS INCLUDING DATES
N.Y. CPLR 312-A