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Case 1:17-cv-00666 Document 1 Filed 04/14/17 Page 1 of 12

UNITED STATES DISTRICT COURT


FOR THE DISTRICT OF COLUMBIA

)
VOX MEDIA, INC., )
)
Plaintiff, )
) Civil Action No.: ___________
v. )
)
GRAIG MANSFIELD, )
)
Defendant. )
)
)

COMPLAINT

Plaintiff Vox Media, Inc. (Vox Media), a Delaware corporation, submits this complaint

against Defendant Graig Mansfield and alleges as follows:

NATURE OF THE ACTION

1. Graig Mansfield was a Procurement Manager for Vox Media from August 2012

to June 2015. In this position, he was entrusted with the management of corporate assets,

including rewards-program accounts for corporate credit cards and frequent-flier programs.

Although he agreed to serve the company faithfully and use his best efforts to promote its

interests, Mansfield abused the trust Vox Media placed in him, defrauding his employer by

taking over $200,000 worth of assets for his own use. Vox Media brings this civil action for

fraud, fraudulent concealment, conversion, and unjust enrichment to vindicate its rights and

recover what Mansfield stole.

PARTIES

2. Vox Media is a corporation duly organized and existing under the laws of the

State of Delaware with its principal place of business in Washington, D.C. Vox Media is a fast-

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growing digital media company that creates and distributes content online through eight

influential brands, covering sports, culture, technology, and politics, among other subjects.

3. Upon information and belief, Mansfield is a natural person residing in Atlanta,

Georgia.

JURISDICTION AND VENUE

4. This Court has subject matter jurisdiction over this action pursuant to 28 U.S.C

1332. The parties in this matter are completely diverse in citizenship and the amount in

controversy exceeds $75,000.

5. This Court has personal jurisdiction over Mansfield pursuant to D.C. Code 13-

432(a) because he caused tortious injury in the District by acts and omissions in the District.

6. Venue is proper in this District pursuant to 28 U.S.C. 1391 because a substantial

part of the events or omissions giving rise to the claims occurred in this District.

STATEMENT OF FACTS

7. Vox Media was founded as an innovative producer of digital content, focusing on

telling high-quality stories across various platforms.

8. In August 2012, Vox Media hired Mansfield as Procurement Manager for Vox

Media. Mansfield worked in that position for three years before he departed.

9. Generally, Mansfields position involved coordinating procurement methods;

managing data from company cards, expense reports, and corporate accounts for budget

reporting; and monitoring spend levels. Mansfield worked within the finance and accounting

department.

10. His responsibilities included managing the corporate credit card account at Silicon

Valley Bank (SVB) and various frequent-flier and travel rewards accounts on behalf of Vox

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Media. Vox Media had accounts with American Airlines, Southwest Airlines, and Amtrak,

among others. Mansfield was responsible for setting up the frequent-flier and travel rewards

accounts and processing reimbursement requests. Mansfield also helped authorized individuals

at Vox Media obtain corporate credit cards to use for company business. Mansfields job was

based in Washington, D.C. and did not require travel.

11. Upon Mansfields employment, Vox Media provided Mansfield an Employee

Handbook. He acknowledged it and agreed to abide by its terms, including its list of strictly

prohibited activities. Those activities expressly included damage, destruction, or theft of

property. In accepting his position, Mansfield also agreed to serve the Company faithfully and

use [his] best efforts to promote its interests.

12. Vox Media was a start-up when Mansfield joined, and it had no policy in place

for management of corporate travel.

13. When Mansfield joined, Vox Media had just applied for a corporate credit card

with SVB. Vox Medias Controller submitted an application in May 2012. The application

clearly indicated that the rewards program associated with corporate cards and points from that

program would be for the benefit of the business. SVBs rewards program allowed customers to

convert point balances to cash or merchandise. The account application offered Vox Media the

choice of enrolling the company itself in the SVB rewards program or allowing employees to

enroll in an individual-points program in connection with the account. Vox Media chose to

enroll the company itself rather than authorize rewards points to accrue to individual employees.

Accordingly, all points accrued from company cards under the rewards program would be for

Vox Medias use.

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14. Certain types of employees were provided with a company credit card or

authorization to charge using the account. But individual employees were not authorized to use

company points or accrue points to personal accounts based on the companys transactions.

15. Vox Media also entrusted Mansfield with the establishment and management of

its frequent-flier and other travel rewards accounts. Mansfield opened accounts with American

Airlines and Southwest Airlines on behalf of Vox Media. Vox Media had other rewards

accounts, including with Delta Airlines and Amtrak.

16. The rewards programs all operated along the same lines: the more money Vox

Media spent with each merchant, the more points accrued to Vox Medias account with each.

Account holders could then use points in their accounts to purchase airline travel or merchandise,

or simply convert them to cash-equivalent bonus cards with Mastercard or with other

merchants, which could be used to purchase goods or services.

17. Mansfield gave access to the travel rewards accounts only to himself; no other

Vox Media employee had access to them. Mansfield was also one of very few people who had

access to the SVB credit card. When he discussed the SVB rewards program with another Vox

Media employee, he described it as not very good.

18. During the time Mansfield worked at Vox Media, the company did not dedicate a

specific use to the rewards points it accrued through the company card or the frequent-flier/travel

accounts. Rather, Vox Media was deliberating on what purpose to put the points towhether

for large company events, holiday parties, or the like. In the meantime, the points were to be set

aside until the company had determined a use for them. At no point did the company authorize

individuals to redeem the rewards points or otherwise transfer them for personal use.

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19. Unbeknownst to Vox Media, however, Mansfield betrayed the company, secretly

stealing from it throughout his employment, and even afterwards. He repeatedly used his control

over the corporate credit card and travel accounts to transfer cash to himself or to transfer

rewards points from Vox Medias accounts to his personal accounts. Many times, Mansfield

simply converted the points to cash in the form of $500 MasterCard bonus cards or $100 gift

cards with various merchants and instructed the merchants to send them first to 2241 Eisenhower

Avenue, # 823, Alexandria, VA 22314, and later to 3527A S. Stafford Street, Arlington, VA

22206. But these were not Vox Medias addresses. They were Mansfields personal addresses.

In some cases, he converted the value in the rewards accounts to luxury goods and had those sent

to his home addresses, too. And sometimes he simply bought himself airline tickets using Vox

Medias frequent-flier points.

20. Mansfield never disclosed to Vox Media that he bought luxury items with the

companys rewards account or that he simply paid himself tens of thousands of dollars above the

salary and benefits which Vox Media authorized and reported to the Internal Revenue Service.

21. Mansfield left Vox Media in June 2015. He moved several months later to a new

job in Atlanta, Georgia.

22. Mansfields conduct was so shameless that he even continued this theft long after

he left his position at Vox Media. On February 7, 2016, more than half a year after he left Vox

Media, Mansfield used Vox Media assets to purchase a TAG Heuer Men's Aquaracer Stainless

Steel Watch with Blue Dial worth $1,713:

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23. Vox Media never authorized Mansfield to use the companys rewards account for

his own benefit. To the contrary, Vox Media entrusted him with a special duty of care to manage

these corporate assets for the benefit of the company and to guard against their misuse.

24. Mansfield deprived Vox Media of money, valuable assets, and control over its

own property.

25. Vox Media discovered Mansfields theft only after he left. After Mansfield left

the company in June 2015, his roles and responsibilities associated with managing the

Companys travel programs transitioned to a Senior Accountant. In December 2015, a new

Corporate Controller was hired.

26. In April 2016, the Senior Accountant discovered that Mansfield was still listed as

the contact for the SVB credit card account and the travel accounts. Understanding the company

never to have used the balances in these accounts, he presumed them to be dormant and asked

SVB for a report of account activity.

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27. To his surprise, SVB disclosed that the accounts had been quite active and

provided the Senior Accountant with a report on that activity. The report revealed Mansfields

massive diversion to Mansfield of rewards credits in Vox Medias corporate account at SVB.

28. The records showed that Mansfields redemption of rewards from the account

with SVB was deliberate and consistent. Beginning March 2013, Mansfield began redeeming

rewards from the account, and records show that he did it with regularity; the redemption history

on the account shows activity for almost three years.

29. The Senior Accountant found a similar pattern when he investigated Vox Medias

accounts with Delta Airlines and American Airlines. In each case, Mansfield had set himself as

Vox Medias only contact with the travel provider and used that control over the accounts to cash

in for his own personal benefit. After discovering the scheme, Vox Media had most of its

vendors change the account access and cut off Mansfields ability to continue it.

30. So far, Vox Media has confirmed that Mansfield stole over $210,000 worth of

goods and credits through this scheme. But as Mansfield himself was the person in charge of

these accounts, Vox Media cannot be certain that it has uncovered the entire scope of his fraud.

31. Vox Media has still not been able to determine how much Mansfield

misappropriated from the Southwest Airlines and Amtrak accounts. As both Southwest Airlines

and Amtrak are popular travel companies with Vox Media employees, the rewards points for

those accounts accrue quickly. It is conceivable that the value Mansfield diverted from those

accounts could significantly add to the total damages in this case.

32. Vox Media seeks relief on the following bases:

COUNT I
Fraud

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33. The allegations in Paragraphs 1-32 are re-alleged and incorporated herein by

reference.

34. Vox Media entrusted its corporate card account and various frequent-flier and

travel accounts to Mansfield during his time as an employee. Mansfield alone had access to said

accounts. It was his responsibility to manage the accounts on behalf of the company.

35. Consistently throughout the course of his employment at Vox Media and for more

than half a year after his departure, Mansfield knowingly and intentionally took rewards from

Vox Medias corporate, frequent-flier, and travel accounts, and transferred rewards points to his

personal account and/or to bonus cards for his own personal use.

36. Upon commencing employment, Vox Media provided Mansfield with an

Employee Handbook that made clear certain common sense understandings: Mansfield could not

engage in theft of company property or misuse of company funds. Mansfield acknowledged, in

writing, that he understood and accepted this.

37. Mansfield intended to deceive Vox Media and obscure his theft of rewards points.

To that end, Mansfield told other employees that the SVB rewards program was not very good,

to downplay how many rewards points Vox Media had earned. Moreover, Mansfield retained

sole access to these accounts and did not share access information with any other employees,

ensuring that only he could see the value of rewards accrued and enabling his surreptitious

practice of cashing in rewards for his personal benefit. Mansfield further deceived Vox Media

by having the fruits of his scheme, such as the many $500 Mastercards, other gift cards, the

$1750 watch, and other merchandise sent to his home address rather than the Vox Media address

listed on the relevant accounts.

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38. Vox Media relied on Mansfields representations that he would faithfully manage

the accounts and not engage in theft of company property. Based on those representations, Vox

Media assumed that the rewards points accrued from the company credit card and various travel

accounts were minimal but available for Vox Medias use in accordance with the terms of the

merchants rewards programs.

39. At all relevant times, Vox Media was unaware of Mansfields deception. It was

only months after Mansfield departed that Vox Media realized that Mansfield had flagrantly

stolen rewards points from the corporate account and moreover, had continued to do so even

after departing from the company.

40. As a proximate result of Mansfields fraud, Vox Media has suffered a loss of at

least $200,000, possibly more, in an amount to be proved at trial.

COUNT II
Fraudulent Concealment

41. The allegations in Paragraphs 1-40 are re-alleged and incorporated herein by

reference.

42. Vox Media entrusted its corporate card account and various frequent-flier and

travel accounts to Mansfield during his time as an employee. Mansfield alone had access to said

accounts. It was his responsibility to manage the account on behalf of the company.

43. Consistently throughout the course of his employment at Vox Media and for more

than half a year after his departure, Mansfield knowingly and intentionally took rewards from

Vox Medias corporate, frequent-flier, and travel accounts, and transferred rewards points to his

personal account and/or to "bonus" cards for his own personal use.

44. Despite his duty to act as an honest employee, and to refrain from theft of

company property or misuse of company funds, Mansfield concealed these facts from Vox

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Media with the intent to defraud Vox Media of its assets in the corporate account. Mansfield hid

evidence of his deception by retaining sole access to the corporate, frequent-flier, and travel

accounts, by describing the SVB rewards program as not very good, and by instructing the

rewards program companies to send the stolen assets to his home address rather than to Vox

Media.

45. At all relevant times, Vox Media was unaware of Mansfields deception. It was

only months after Mansfield departed that Vox Media realized that Mansfield had flagrantly

stolen rewards points from the corporate account and moreover, had continued to do so even

after departing from the company.

46. As a proximate result of Mansfields concealment, Vox Media has suffered a loss

of at least $200,000, possibly more, in an amount to be proved at trial.

COUNT III
Conversion

47. The allegations in Paragraphs 1-46 are re-alleged and incorporated herein by

reference.

48. Vox Media had clear ownership over the assets in the frequent-flier and corporate

accounts.

49. Furthermore, Vox Media never authorized any employees to transfer points or

miles from those accounts into employees personal accounts.

50. Mansfield wrongfully transferred frequent-flier miles and other corporate assets

from those accounts into his own personal account and converted those points into cash, cash

equivalents, or luxury goods.

51. As a proximate result of Mansfields acts of conversion, Vox Media has suffered

losses of at least $200,000, possibly more, in an amount to be proved at trial.

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COUNT IV
Unjust Enrichment

52. The allegations in Paragraphs 1-51 are re-alleged and incorporated herein by

reference.

53. Mansfield enriched himself unjustly during and after his employment at Vox

Media, using Vox Medias reward points.

54. He also had the benefit of access to the corporate and frequent-flier accounts. He

wrongfully used his access privileges to enrich himself. Moreover, after his employment had

concluded, he continued to access Vox Medias accounts to transfer more points to his own

account.

55. As a proximate result of Mansfields conduct, Vox Media has suffered losses of at

least $200,000, possibly more, in an amount to be proved at trial.

PRAYER FOR RELIEF

WHEREFORE, Plaintiff Vox Media, respectfully requests that this Court:

(a) Award compensatory damages in an amount to be proven at trial, and which may

exceed $200,000, depending on the full scope of what Mansfield misappropriated from

Vox Media;

(b) Award punitive damages for Mansfields intentional, willful, and wanton conduct,

which was in reckless disregard of Vox Medias rights;

(c) Grant such other relief as the Court deems just and proper.

JURY DEMAND

Pursuant to Federal Rule of Civil Procedure 38, Plaintiff Vox Media hereby demands trial

by jury.

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Case 1:17-cv-00666 Document 1 Filed 04/14/17 Page 12 of 12

April 14, 2017 Respectfully submitted,

_____________________
Patrick ODonnell (DC Bar # 459360)
Harris, Wiltshire & Grannis LLP
1919 M Street, NW, 8th Floor
Washington, DC 20036
podonnell@hwglaw.com
Counsel for Vox Media, Inc.

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Case 1:17-cv-00666 Document 1-1 Filed 04/14/17 Page 1 of 2
CIVIL COVER SHEET
JS-44 (Rev. 7/16 DC)
I. (a) PLAINTIFFS DEFENDANTS
Vox Media, Inc. Graig Mansfield

11001
(b) COUNTY OF RESIDENCE OF FIRST LISTED PLAINTIFF _____________________ COUNTY OF RESIDENCE OF FIRST LISTED DEFENDANT _____________________
(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)
NOTE IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED

(c) ATTORNEYS (FIRM NAME, ADDRESS, AND TELEPHONE NUMBER) ATTORNEYS (IF KNOWN)

Harris, Wiltshire & Grannis LLP Jason M. Kalafat


1919 M Street NW, Floor Eight Price Benowitz LLP
Washington, DC 20036 409 7th St. NW, Suite 200
Washington, DC 20004
II. BASIS OF JURISDICTION III. CITIZENSHIP OF PRINCIPAL PARTIES (PLACE AN x IN ONE BOX FOR
(PLACE AN x IN ONE BOX ONLY) PLAINTIFF AND ONE BOX FOR DEFENDANT) FOR DIVERSITY CASES ONLY!
PTF DFT PTF DFT
1 U.S. Government 3 Federal Question
Plaintiff (U.S. Government Not a Party) Citizen of this State 1 1 Incorporated or Principal Place 4 4
of Business in This State
2 U.S. Government 4 Diversity Citizen of Another State 2 2 5 5
Incorporated and Principal Place
Defendant (Indicate Citizenship of
of Business in Another State
Parties in item III) Citizen or Subject of a 3 3
Foreign Country Foreign Nation 6 6

IV. CASE ASSIGNMENT AND NATURE OF SUIT


(Place an X in one category, A-N, that best represents your Cause of Action and one in a corresponding Nature of Suit)
A. Antitrust B. Personal Injury/ C. Administrative Agency D. Temporary Restraining
Malpractice Review Order/Preliminary
410 Antitrust Injunction
310 Airplane 151 Medicare Act
315 Airplane Product Liability Any nature of suit from any category
320 Assault, Libel & Slander Social Security
may be selected for this category of
861 HIA (1395ff)
330 Federal Employers Liability case assignment.
862 Black Lung (923)
340 Marine
863 DIWC/DIWW (405(g)) *(If Antitrust, then A governs)*
345 Marine Product Liability
864 SSID Title XVI
350 Motor Vehicle
865 RSI (405(g))
355 Motor Vehicle Product Liability
Other Statutes
360 Other Personal Injury
891 Agricultural Acts
362 Medical Malpractice
893 Environmental Matters
365 Product Liability
890 Other Statutory Actions (If
367 Health Care/Pharmaceutical
Administrative Agency is
Personal Injury Product Liability
Involved)
368 Asbestos Product Liability

E. General Civil (Other) OR F. Pro Se General Civil


Real Property Bankruptcy Forfeiture/Penalty
210 Land Condemnation 422 Appeal 27 USC 158 625 Drug Related Seizure of 470 Racketeer Influenced
220 Foreclosure 423 Withdrawal 28 USC 157 Property 21 USC 881 & Corrupt Organization
230 Rent, Lease & Ejectment 690 Other 480 Consumer Credit
240 Torts to Land Prisoner Petitions 490 Cable/Satellite TV
245 Tort Product Liability 535 Death Penalty 850 Securities/Commodities/
290 All Other Real Property 540 Mandamus & Other Other Statutes Exchange
550 Civil Rights 375 False Claims Act 896 Arbitration
Personal Property 555 Prison Conditions 376 Qui Tam (31 USC 899 Administrative Procedure
370 Other Fraud 560 Civil Detainee Conditions 3729(a)) Act/Review or Appeal of
371 Truth in Lending of Confinement 400 State Reapportionment Agency Decision
380 Other Personal Property 430 Banks & Banking 950 Constitutionality of State
Damage Property Rights 450 Commerce/ICC Statutes
385 Property Damage 820 Copyrights Rates/etc. 890 Other Statutory Actions
Product Liability 830 Patent 460 Deportation (if not administrative agency
840 Trademark 462 Naturalization review or Privacy Act)
Application
Federal Tax Suits 465 Other Immigration
870 Taxes (US plaintiff or
Actions
defendant)
871 IRS-Third Party 26 USC 7609
Case 1:17-cv-00666 Document 1-1 Filed 04/14/17 Page 2 of 2
G. Habeas Corpus/ H. Employment I. FOIA/Privacy Act J. Student Loan
2255 Discrimination
530 Habeas Corpus General 442 Civil Rights Employment 895 Freedom of Information Act 152 Recovery of Defaulted
510 Motion/Vacate Sentence (criteria: race, gender/sex, 890 Other Statutory Actions Student Loan
463 Habeas Corpus Alien national origin, (if Privacy Act) (excluding veterans)
Detainee discrimination, disability, age,
religion, retaliation)

*(If pro se, select this deck)* *(If pro se, select this deck)*

K. Labor/ERISA L. Other Civil Rights M. Contract N. Three-Judge


(non-employment) (non-employment) Court
110 Insurance
710 Fair Labor Standards Act 441 Voting (if not Voting Rights 120 Marine 441 Civil Rights Voting
720 Labor/Mgmt. Relations Act) 130 Miller Act (if Voting Rights Act)
740 Labor Railway Act 443 Housing/Accommodations 140 Negotiable Instrument
751 Family and Medical 440 Other Civil Rights 150 Recovery of Overpayment
Leave Act 445 Americans w/Disabilities & Enforcement of
790 Other Labor Litigation Employment Judgment
791 Empl. Ret. Inc. Security Act 446 Americans w/Disabilities 153 Recovery of Overpayment
Other of Veterans Benefits
448 Education 160 Stockholders Suits
190 Other Contracts
195 Contract Product Liability
196 Franchise

V. ORIGIN
1 Original 2 Removed 3 Remanded 4 Reinstated 5 Transferred 6 Multi-district 7 Appeal to 8 Multi-district
Proceeding from State from Appellate or Reopened from another Litigation District Judge Litigation
Court Court district (specify) from Mag. Direct File
Judge

VI. CAUSE OF ACTION (CITE THE U.S. CIVIL STATUTE UNDER WHICH YOU ARE FILING AND WRITE A BRIEF STATEMENT OF CAUSE.)
Fraud and conversion of Vox Media's accrued rewards points

VII. REQUESTED IN CHECK IF THIS IS A CLASS DEMAND $ 200,000+ Check YES only if demanded in complaint
COMPLAINT ACTION UNDER F R C P 23
JURY DEMAND: YES NO
VIII. RELATED CASE(S)
IF ANY
(See instruction)
YES NO If yes, please complete related case form

4/14/2017
DATE: _________________________
/s/ Patrick O'Donnell
SIGNATURE OF ATTORNEY OF RECORD _________________________________________________________

INSTRUCTIONS FOR COMPLETING CIVIL COVER SHEET JS-44


Authority for Civil Cover Sheet

The JS-44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and services of pleadings or other papers as required
by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the
Clerk of Court for the purpose of initiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk of Court for each civil complaint filed.
Listed below are tips for completing the civil cover sheet. These tips coincide with the Roman Numerals on the cover sheet.

I. COUNTY OF RESIDENCE OF FIRST LISTED PLAINTIFF/DEFENDANT (b) County of residence: Use 11001 to indicate plaintiff if resident
of Washington, DC, 88888 if plaintiff is resident of United States but not Washington, DC, and 99999 if plaintiff is outside the United States.

III. CITIZENSHIP OF PRINCIPAL PARTIES: This section is completed only if diversity of citizenship was selected as the Basis of Jurisdiction
under Section II.

IV. CASE ASSIGNMENT AND NATURE OF SUIT: The assignment of a judge to your case will depend on the category you select that best
represents the primary cause of action found in your complaint. You may select only one category. You must also select one corresponding
nature of suit found under the category of the case.

VI. CAUSE OF ACTION: Cite the U.S. Civil Statute under which you are filing and write a brief statement of the primary cause.

VIII. RELATED CASE(S), IF ANY: If you indicated that there is a related case, you must complete a related case form, which may be obtained from
the Clerks Office.

Because of the need for accurate and complete information, you should ensure the accuracy of the information provided prior to signing the form.
Case 1:17-cv-00666 Document 1-2 Filed 04/14/17 Page 1 of 2

AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT


for the
District of Columbia

Vox Media, Inc. )


)
)
)
Plaintiff(s) )
)
v. Civil Action No.
)
Graig Mansfield )
)
)
)
Defendant(s) )

SUMMONS IN A CIVIL ACTION

To: (Defendants name and address) Graig Mansfield


5304 Abercorn Avenue
Atlanta, GA 30346

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 plaintiffs attorney,
whose name and address are: Patrick O'Donnell
Harris, Wiltshire & Grannis LLP
1919 M Street NW, Floor Eight
Washington, DC 20036

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: 04/14/2017
Signature of Clerk or Deputy Clerk
Case 1:17-cv-00666 Document 1-2 Filed 04/14/17 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 the court unless required by Fed. R. Civ. P. 4 (l))

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) ; or

I left the summons at the individuals 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 individuals last known address; or

I served the summons on (name of individual) , who is


designated by law to accept service of process on behalf of (name of organization)
on (date) ; or

I returned the summons unexecuted because ; or

Other (specify):

My fees are $ for travel and $ for services, for a total of $ 0.00 .

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

Date:
Servers signature

Printed name and title

Servers address

Additional information regarding attempted service, etc: