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Case 2:13-cv-00091-TFM Document 1-4 Filed 01/16/13 Page 1 of 2
EXHIBIT 3
Case 2:13-cv-00091-TFM Document 1-4 Filed 01/16/13 Page 2 of 2
Certificate of Registration
Title
This Certificate issued under the seal of the Copyright
Office in accordance with title 17, United States Code,
attests that registration has been made for the work
identified below. The information on this certificate has
been made a part of the Copyright Office records.
Register of Copyrights, United States of America
Title of Wo1k: Wine and Dine Fun Choker CM862CK
Completion/ Publication
Year of Completion: 2010
Registration Number
VA 1-836-897
Effective date of
registmtion:
September 20, 2012
Date of 1st Publication: May 1, 2010 Nation of 1st Publication: United States
Author
Ill Author: Sabika, h1c.
Author Created: jewelry design
Work made for hire: Yes
Citizen of: United States Domiciled in: United States
Copyright claimant
Copyright Claimant: Sabika, h1c.
6450 Steubenville Pike, Pittsburgh, PA, 15205, United States
Rights and Permissions
Organization Name: Sabika, h1c.
Name: Jennifer Schlieper
Email: jennifer.schlieper@sabika-jewelry.com
Address: 6450 Steubenville Pike
Telephone: 412-580-7440
Certification
Pittsburgh, PA 15205
Name: Jennifer Schlieper
Date: September 20, 2012
Page 1 of 1
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 1 of 11
EXHIBIT4
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 2 of 11
itt ~ t a t e ~ of mert
mnit.eb ~ t a t . e . S ~ a t . e n t anb 'QI;rabemath ffice t{f
Reg. No. 4,189,055 SABIKA, INC. (PENNSYLVANIA CORPORATION)
510 MIRANDA A VENUE
Registered Aug. 14,2012 PITTSBURGlLPA 15241
Int. Cl.: 35
SERVICE MARK
PRINCIPAL REGISTER
D!redot ot'the UnitcJ StiJIC.!. l';tt.:nt and l'ti!Jcm:uk Ollke
FOR: RETAIL SERVICES BY DIRECT SOLICITATION BY SALES AGENTS IN THE FIELD
OF JEWELRY, IN CLASS 35 (U.S. CLS. 100, 101 AND 102).
FIRST USE 9-23-2009; IN COMMERCE 9-23-2009.
OWNER OF U.S. REG. NO. 3,731,881.
NO CLAIM IS MADE TO THE EXCLUSIVE RIGHT TO USE "AUSTRIAN CRYSTAL JEW-
ELRY",APARTFROMTHEMARKAS SHOWN.
THE MARK CONSISTS OF THE TEXT "AUSTRIAN CRYSTAL JEWELRY" ABOVE AND
OFFSET LEFT OF THE TERM "SABIKA" WITH A HEART IMAGE ENCLOSING THE LAST
THREE LETTERS.
SER. NO. 85-343,406, FILED 6-10-2011.
WILLIAM P. SHANAHAN, EXAMINING ATTORNEY
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 3 of 11
REQUIREMENTS TO MAINTAIN YOUR FEDERAL
TRADEMARK REGISTRATION
WARNING: YOUR REGISTRATION WILL BE CANCELLED IF YOU DO NOT FILE THE
DOCUMENTS BELOW DURING THE SPECIFIED TIME PERIODS.
Requirements in the Fiist Ten Years*
What and When to File:
First Filing Deadline: You must file aDeclarationofUse (or Excusable Nonuse) between the
5th and 6th years after the registration date. See 15 U.S. C. 1058, 1141k. If the declaration is
accepted, the registration will continue in force for the remainder of the len-year period, calculated
from the registration date, unless cancelled by an order of the Conunissioner for Trademarks or a
fede ra1 co uri.
Second Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) and an
Application for Renewal between the 9th and lOth years after the registration date.*
See 15 U.S.C. 1059.
Requirements in Successive Ten-Year Pc1iods*
What and When to File:
You must file a Declaration of Use (or Excusable Nonuse) and anApplicationfor Renewal between
every 9th and lOth-year period, calculated from the registration date.*
Grace Period Filings*
The above documents will be accepted as timely if filed within six months after the deadlines listed above
with the payment of an additional fee.
The United States Patent and Trademark Office (USPTO) will NOT send you any future notice or
I'emindeJ' of these filing requhements.
*ATTENTION MADRID PROTOCOL REGISTRANTS: The holder of an international registration with
an ell.iension of protection to the United States under the Madrid Protocol must timely file the Declarations
of Use (or Excusable Nonuse) referenced above directly with the USPTO. The time periods for filing are
based on Ute U.S. registration date (not the intemational registration date). The deadlines and grace periods
for Ute Declarations of Use (or Excusable Nonuse) are identical to those for nationally issued registrations.
See 15 U. S.C. 1058, 114lk. Howeve1; owners ofintemational registrations do not file renewal applications
at the USPTO. Instead, Ute holder must file a renewal of the underlying intemational registration at UIC
lntemational Bureau of the World Intellectual Property Organization, under Article 7 of the Madrid Protocol,
before the expiration of each ten-year term of protection, calculated from the date of the international
registration. See 15 U .S.C. 114lj. For more infonnation and renewal fonns for the intemational registration,
see http://www.wipo.int/madrid/en/.
NOTE: Fees and requirements for maintaining registrations are subject to change. Please check the
USPTO website for further information. With the exce!ltion of renewal a!l!llications fo1 registered
extensions of !lrotection, you can file the registration maintenance documents referenced above online
at http://www.uspto.gov.
Page: 2 I RN # 4,189,055
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 4 of 11
\\\tt ~ t a t e ~ of mert
Wniteb ~ t a t e . t i tlatent anb \Jttabemarh ffice Cq-
Reg. No. 4,087,637
I
SABIKA, INC. (PENNSYLVANIA CORPORATION)
510 MIRANDA AVENUE
Registered Jan. 17, 2012 PITTSBURGH, PA 1524I
Int. Cl.: 35
SERVICE MARK
PRINCIPAL REGISTER
Director of the United States PJtent and Trademark Office
FOR: RETAIL SERVICES BY DIRECT SOLICITATION BY SALES AGENTS IN Tim FIELD
OF JEWELRY, IN CLASS 35 (U.S. CLS. 100, IOI AND 102).
FIRST USE 9-23-2009; IN COMMERCE 9-23-2009.
THE MARK CONSISTS OF STANDARD CHARACTERS WITHOUT CLAIM TO ANY PAR-
TICULAR FONT, STYLE, SIZE, OR COLOR.
OWNER OF U.S. REG. NO. 3,731,881.
SER. NO. 85-343,359, FILED 6-10-20 II.
WILLIAM P. SHANAHAN, EXAMINING ATTORNEY
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 5 of 11
REQUIREMENTS TO MAINTAIN YOUR FEDERAL
TRADEMARK REGISTRATION
WARNING: YOUR REGISTRATION WILL BE CANCELLED IF YOU DO NOT FILE THE
DOCUMENTS BELOW DURING THE SPECIFillD TIME PERIODS.
Requirements in the First Ten Years*
What and When to File:
First Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) between the
5th and 6th years after the registration date. See 15 U.S.C. 1058, 1141k. If the declaration is
accepted, the registration will continue in force for the remainder ofthe ten-year period, calculated
from the registration dale, unless cancelled by an order of the Commissioner for Trademarks or a
federal comt.
Second Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) and an
Application for Renewal between the 9th and lOth years after the registration date.*
See 15 U.S.C. 1059.
Requirements in Successive Ten-Year Periods*
What and When to File:
You must file a Declaration ofUse (or Excusable Nonuse) and an Application for Renewal between
every 9th and 1Oth-year period, calculated from the registration date.*
Grace Pel'iod Filings*
The above documents will be accepted as timely if filed within six months after the deadlines listed above
with the payment of an additional fee.
The United States Patent and Trademark Office (USPTO) will NOT send you any future notice or
reminder of these filing requirements.
*ATTENTION MADRID PROTOCOL REGISTRANTS: The holder of an international registration with
an extension of protection to the United States under the Madrid Protocol must timely file the Declarations
of Use (or Excusable Nonuse) referenced above directly with the USPTO. The time periods for filing are
based on the U.S. registration date (not the international registration date). The deadlines and grace periods
for the Declarations of Use (or Excusable Nonuse) are identical to those for nationally issued registrations.
See 15 U .S.C. 1058, 1141k. However, owners of intemational registrations do not file renewal applications
at the USPTO. Instead, the holder must file a renewal of the underlying intemational registration at the
lntemational Bureau of the World Intellectual Property Organization, under Atticle 7 of the Madrid Protocol,
before the expiration of each ten-year tenn of protection, calculated from the date of the intemational
registration. See 15 U .S.C. 1141j. For more information and renewal forms for the international registration,
see http://www.wipo.int/madridlen/.
NOTE: Fees and requirements for maintaining registrations are subject to change. Please check the
USPTO website for furthet information. With the exception of renewal applications for registered
extensions of protection, you can file the registration maintenance documents referenced above online
at http://www.uspto.gov.
Page: 2 I RN # 4,087,637
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 6 of 11
SABIKA IS THE PROJVliSE OF A
SMILE, THE BEGJNNING OF A
STORY AND THE END OF GOING
UNNOTICED.
Reg. No. 4,087,021 sABIKA, INc. (PENNSYLVANIA coRPoRATION)
510 MIRANDA AVENUE
Registered Jan. 17, 2012 PITTSBURGH, PA 15241
Int. Cl.: 35
SERVICE MARK
PRINCIPAL REGISTER
Director of the United States PJtent and Trndemurk Office
FOR: RETAIL SERVICES BY DIRECT SOLICITATION BY SALES AGENTS IN THE FIELD
OF JEWELRY, IN CLASS 35 (U.S. CLS. 100, 101 AND 102).
FIRST USE 5-31-2010; IN CO!v!MERCE 5-31-2010.
THE MARK CONSISTS OF STANDARD CHARACTERS WITHOUT CLAIM TO ANY PAR-
TICULAR FONT, STYLE, SIZE, OR COLOR.
OWNER OF U.S. REG. NO. 3,731,881.
SER. NO. 85-321,647, FILED 5-16-2011.
WILLIAM P. SHANAHAN, EXAMINING ATTORNEY
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 7 of 11
REQUIREMENTS TO MAINTAIN YOUR FEDERAL
TRADEMARK REGISTRATION
WARNING: YOUR REGISTRATION WILL BE CANCELLED IF YOU DO NOT FILE THE
DOCUMENTS BELOW DURING THE SPECIFIED TIME PERIODS.
Requirements in the First Ten Years*
What and When to File:
First Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) between the
5th and 6th years after the registration date. See 15 U.S.C. 1058, 1141k. If the declaration is
accepted, the registration will continue in force for the remainder of the ten-year period, calculated
from the registration date, unless cancelled by an order of the Commissioner for Trademarks or a
federal comt.
Second Filing Deadline: You must file a Declaration of Usc (or Excusable Nonuse) and an
Application for Renewal between the 9th and lOth years after the registration date.*
See 15 U.S.C. 1059.
Requirements in Successive Ten-Year Periods*
What and When to File:
You must file a Declaration ofUse (or Excusable Nonuse) and an Application for Renewal between
every 9th and I Oth-year period, calculated from the registration date.*
Grace Period Filings*
The above documents will be accepted as timely if filed within six months after the deadlines listed above
with the payment of m1 additional fee.
The United States Patent and Trademark Office (USPTO) will NOT send you any future notice or
reminder of these filing requirements.
*ATTENTION MADRID PROTOCOL REGISTRANTS: The holder of an international registration with
an extension of protection to the United States under the Madrid Protocol must timely file the Declmations
of Use (or Excusable Nonuse) referenced above directly with the USPTO. The time periods for filing are
based on the U.S. registration date (not the international registration date). The deadlines m1d grace periods
for the Declarations of Use (or Excusable Nonuse) are identical to those for nationally issued registrations.
See 15 U .S.C. 1058, 114lk. However, owners of international registrations do not file renewal applications
at the USPTO. Instead, the holder must file a renewal of the underlying intemational registration at the
Intemational Bureau of the World Intellectual Properly Orgm1ization, under Article 7 of the Madrid Protocol,
before the expiration of each ten-ycm tenn of protection, calculated from the dale of the intemational
registration. See 15 U.S.C. 1141j. For more information and renewal forms for the international registration,
sec hllp://www.wipo.int/madridlen/.
NOTE: Fees and requirements for maintaining registrations are subject to change. Please check the
USPTO website for further information. With the exception of renewal applications for registered
extensions of pmtection, you can file the registration maintenance documents referenced above online
at hllp://www.uspto.gov.
Page: 2 I RN # 4,087,021
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 8 of 11
l\\ttb of ntert
mntteb !latent anb 'Orrabemark ffice
Reg. No. 4,077,226
SABIKA, INC. (PENNSYLVANIA CORPORATION)
510MIRANDAAVENUE
Registered Dec. 27,2011 PITTSBURGH,PA 15241
Int. Cis.: 14, 18, 25 and FOR: JEWELRY, IN CLAss 14(U.s. cLs. 2,27,28ANDSO).
35
TRADEMARK
SERVICE MARK
PRINCIPAL REGISTER
Dlrcclm ofthl! United and fmJ..:m;uk Olllc<.!
FIRST USE 8-27-2009; IN CO:NIMERCE 8-27-2009.
FOR: TOTE BAGS, IN CLASS 18 (U.S. CLS. 1, 2, 3, 22AND41).
FIRST USE 3-2-2011; IN CO:NIMERCE 3-2-2011.
FOR: APRONS; I-SHIRTS, IN CLASS 25 (U.S. CLS. 22 AND 39).
FIRST USE 6-8-2009; IN CO:NIMERCE 6-8-2009.
FOR: RETAIL SERVICES BY DIRECT SOLICITATION BY SALES AGENTS IN THE FillLD
OF JEWELRY, IN CLASS 35 (U.S. CLS. 100, 101 AND 102).
FIRST USE 9-23-2009; IN CO:NIMERCE 9-23-2009.
Tim MARK CONSISTS OF A FANCIFUL HEART.
SER. NO. 85-343,470, FILED 6-10-2011.
WILLIAM P. SHANAHAN, EXAMINING ATTORNEY
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 9 of 11
REQUIREMENTS TO MAINTAIN YOUR FEDERAL
TRADEMARK REGISTRATION
WARNING: YOUR REGISTRATION WILL BE CANCELLED IF YOU DO NOT FILE THE
DOCUMENTS BELOW DURING THE SPECIFIED TIME PERIODS.
Requirements in the Fitst Ten Yeats*
What and When to File:
First Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) between the
5th and 6th years after the registration date. See 15 U.S. C. 1058, 1141k. If the declaration is
accepted, the registration will continue in force for the remainder of the ten-year period, calculated
from the registration date, unless cancelled by an order of the Commissioner for Trademarks or a
federal court.
Second Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) and an
Application for Renewal between the 9th and lOth years after the registration date.*
See 15 U.S. C. 1059.
Requirements in Successive Ten-Year Petiods*
What and When to File:
You must file aDeclarationofUse (or Excusable Nonuse) and anApplicationforRenewal between
every 9th and lOUt-year period, calculated from Ute registration date.*
Grace Period Filings*
The above documents will be accepted as timely if filed wiUtin sLx months after Ute deadlines listed above
with the payment of an additional fee.
The United States Patent and Trademark Office (USPTO) will NOT send you any future notice or
reminder of these filing t'C![ttirements.
*ATTENTION MADRID PROTOCOL REGISTRANTS: The holder of an international registration with
an of protection to the Urtited States under the Madrid Protocol must timely file tl1e Declarations
of Use (or Excusable Nonuse) referenced above directly with the USPTO. The time petiods for filing are
based on the U.S. registration date (not the intemational registration date). The deadlines and grace periods
for Ute Declarations of Use (or Excusable Nonuse) are identical to those for tm!ionally issued registrations.
See 15 U.S. C. 1058, 1141k. owners of intenmtimml registrations do not file renewal applications
at the USPTO. Instead, tl1e holder must file a renewal of the underlying intemalional registration at tl1e
Intemational Bureau of the World Intellectual Property Orgmlization, under Article 7 of the Madrid Protocol,
before tlte expiration of each ten-year term of protection, calculated from the date of tl1e international
registration. See 15 U.S.C. ll4lj. For more infonnationand renewal forms for the intemational registration,
see http://www.wipo.int/madridlen/.
NOTE: Fees and requitements fmmaintaining registmtions are subject to change. Please check the
USPTO website for further information. With the exception of renewal all[!lications fot registered
extensions of [ll'Otection, you can file the registration maintenance documents referenced above online
at http://www.uspto.gov.
Page: 2 I RN # 4,077,226
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 10 of 11
\\\t of flfmert
'mlniteb ,Jlatent anb 'Otrabemarh ffice
Reg. No. 3,731,881
I I
MAYR, KARIN (UNITED STATES INDIVIDUAL)
510 MIRANDA DRIVE
Registered Dec. 29,2009 PITTSBURGH, PA 1s241
Amended Oct. 25, 2011
Int. CI.: 14
TRADEMARK
PRINCIPAL REGISTER
of the United State;, Patent and Tnulemark Office
FOR: [ PRECIOUS METALS AND THEIR ALLOYS; ] JEWELRY; [ PRECIOUS STONES;
HOROLOGICAL AND CHRONOMETIC INSTRUMENTS; AMULETS;] PINS; BRACELETS;
[WATCH STRAPS; WRIST WATCHES; JEWELRY OF AMBER; BROOCHES; THREADS OF
PRECIOUS METAL; UNWROUGHT OR SEMI-WROUGHT PRECIOUS METALS; ALLOYS
OF PRECIOUS METAL; UNWROUGHT OR BEATEN GOLD; GOLD THREADS; JEWELRY
MADE OF ORMOLU; SEMI-PRECIOUS STONES; ] NECKLACES; [HAT ORNAMENTS OF
PRECIOUS METAL; JEWELRY CHAINS; WATCH CHAINS; CUFF-LINKS; MEDALLIONS;
TIE CLIPS; TIE PINS; ORNAMENTAL PINS; ORNAMENTS OF PRECIOUS METALS; ]
EARRINGS; [ PEARLS; l RINGS; [ KEY RINGS OF PRECIOUS METAL; WATCH FOBS;
BUCKLES FOR WATCH STRAPS; UNWROUGHT OR CHASED SILVER; SILVER THREADS;
SILVER ORNAMENTS; PASTE JEWELRY; JEWELRY TRINKETS], IN CLASS I4 (U.S. CLS.
2, 27, 28 AND 50).
FIRST USE 8-0-2000; IN COMMERCE 8-0-2000.
TI-lE MARK CONSISTS OF S1i\NDARD CHARACTERS WITHOUT CLAIM TO ANY PAR-
TICULAR FONT, STYLE, SIZE, OR COLOR.
SER. NO. 77-261,515, FILED 8-22-2007.
Case 2:13-cv-00091-TFM Document 1-5 Filed 01/16/13 Page 11 of 11
REQUIREMENTS TO MAINTAIN YOUR FEDERAL
TRADElVIARK REGISTRATION
WARNING: YOUR REGISTRATION WILL BE CANCELLED IF YOU DO NOT FILE THE
DOCUMENTS BELOW DURING THE SPECIFIED Tll\'IE PERIODS.
Requirements in the First Ten Years*
What and When to File:
First Filing Demlline: You must file a Declaration of Use (or Excusable Nonuse) between the
5th and 6th years after the registration date. See 15 U.S.C. 1058, 114lk. If the declaration is
accepted, the registration will continue in force for the remainder of the ten-year period, calculated
from the registration date, unless cancelled by an order of the Commissioner for Trademarks or a
federal court.
Second Filing Deadline: You must file a Declaration of Use (or Excusable Nonuse) and an
Application for Renewal between the 9th and lOth years after the registration date.*
See 15 U.S.C. 1059.
Requirements in Successive Ten-Year Periods*
What and When to File:
You must file a Declaration of Use (or Excusable Nonuse) and an Application for Renewal between
every 9th and lOth-year period, calculated from the registration date.*
Grace Pel'iod Filings*
The above documents will be accepted as timely if filed within six months after the deadlines listed above
with the payment of fill additional fee.
The United States Patent and Trademark Office (USPTO) will NOT send you any fitture notice or
reminder of these filing requirements.
*ATTENTION MADRID PROTOCOL REGISTRANTS: The holder of an international registration with
an extension of protection to the United States under the Madrid Protocol must timely file the Declarations
of Use (or Excusable Nonuse) referenced above directly with the USPTO. The time periods for filing are
based on the U.S. registration date (not the international registration date). The deadlines and grace periods
for the Declarations of Use (or Excusable Nonuse) are identical to those for nationally issued registrations.
See 15 U .S.C. 1058, 1141k. However, owners of international registrations do not file renewal applications
at the USPTO. Instead, the holder must file a renewal of the underlying intemational registration at the
International Bureau of the World Intellectual Property Organization, under Article 7 of the Madrid Protocol,
before the expiration of each ten-year tenn of protection, calculated from the date of the international
registration. See 15 U.S.C. 114lj. For more information and renewal forms for the international registration,
sec http://www.wipo.int/madrid/en/.
NOTE: Fees and requirements for maintaining registrations are subject to change. Please check the
USPTO website for fit rther information. With the exception of renewal applications for registered
extensions of protection, you can file the registration maintenance documents referenced above online
at http://www.uspto.gov.
Page: 2/ RN # 3,731,881
Case 2:13-cv-00091-TFM Document 1-6 Filed 01/16/13 Page 1 of 2
AO 440 (Rev. 06/12) Summons in a Civil Action
UNITED STATES DISTRICT COURT
for the
Western District of Pennsylvania
SABIKA, INC.
)
)
)
)
)
)
)
)
)
)
)
)
Plainti.ff(s)
v. Civil Action No.
ANITA KELLY MANFRED, trading and doing
business as BUNG by Anita
Defendant(s)
To: (Defendant's name and address)
SUMMONS IN A CIVIL ACTION
Anita Kelly Manfred,
trading and doing business as BUNG by Anita
1331 Cedar Boulevard
Pittsburgh, PA 15228-1013
A lawsuit has been filed against you.
Within 21 days after service of this summons on you (not counting the day you received it)- or 60 days if you
are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.
P. 12 (a)(2) or (3)- 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: Maxim Waldbaum, Esq. or Charles B. Gibbons, Esq.
Robert D. Katz, Esq. Michael L. Dever, Esq.
Eaton & Van Winkle Christopher A. Amar, Esq.
3 Park Avenue, 16th Floor Buchanan Ingersoll & Rooney PC
New York, NY 10016 One Oxford Centre, 301 Grant Steet, 20th Floor
Pittsburgh, PA 15219
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: 01/16/2013
Signature of Clerk or Deputy Clerk
Case 2:13-cv-00091-TFM Document 1-6 Filed 01/16/13 Page 2 of 2
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)
Civil Action No.
PROOF OF SERVICE
(This section should not be filed with tlte court unless required by Fed. R. Civ. P. 4 (/))
This smmnons for (name of individual and title, if any)
was received by me on (date)
0 I personally served the summons on the individual at (place)
on (date)
------------------------------------------------ ------------------
0 I left the summons at the individual's residence or usual place of abode with (name)
; or
, a person of suitable age and discretion who resides there,
---------------------------------
on (date) , and mailed a copy to the individual's last known address; or
---------------
0 I served the summons on (lwme of individual) , who is
designated by law to accept service of process on behalf of (name of organization)
on (date)
------------------------------------------------
0 I returned the summons unexecuted because
; or
--------------------------------------------
0 Other (spec(/jl):
My fees are$ for travel and $ for services, for a total of$
0.00
-----------
I declare under penalty ofpetjury that this information is true.
Date:
Server's signature
Printed name and title
Server's address
Additional information regarding attempted service, etc:
; or