For Clerk’s Use Only Name of Person Filing: _______________________________________ Mailing Address: _______________________________________ City, State, and Zip Code: _______________________________________ Daytime / Evening Phone: _______________________________________ ATLAS Number (if applicable):_______________________________________ State Bar Number (if applicable):_____________________________________ Self (Without a Lawyer) OR Representing Attorney for Plaintiff / Petitioner or Defendant / Respondent (If Attorney, include State Bar Number) SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number:________________________ (Name of Plaintiff / Petitioner) AFFIDAVIT OF SERVICE (Name of Defendant / Respondent) I received the Summons / Subpoena addressed to _____________________________________________ and dated ______________________________ on this date _______________________________ at this time ______________________________ and I personally served it as follows: Name: _________________________________________________________________________ Date: _________________________________ Place: _________________________________________________________________________ Manner: _________________________________________________________________________ Time: ________________________________ _________________________________________________________________________ I declare under penalty of perjury that the foregoing is true and correct. Date: ___________________________________ Printed Name: Street Address: City, State, Zip: Phone: FEES MILEAGE OTHER ______________________________________ ______________________________________ ______________________________________ ______________________________________ $_____________________ $_____________________ $_____________________ TOTAL ______________________________________ Signature $_____________________ . 00 0 Revised: 8/18/2010 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com