AFFIDAVIT OF SERVICE PETITION FOR ORDER RE: COMMISSION ON HUMAN RIGHTS AND OPPORTUNITIES AND NOTICE OF HEARING JD-CV-69 New 6-98 Public Act 98-245, Sec. 8 COURT USE ONLY STATE OF CONNECTICUT SUPERIOR COURT PETIT INSTRUCTIONS TO PETITIONER Complete the Affidavit (the Docket Number is the number assigned by the clerk to your original petition), attach your return receipts and file the Affidavit with the clerk of court within five days of service being made. AFFIDAVIT OF SERVICE PETITION FOR ORDER RE: COMMISSION ON HUMAN RIGHTS AND OPPORTUNITIES AND NOTICE OF HEARING TO: Superior Court for the Judicial District of Hartford-New Britain at Hartford, 95 Washington St. Hartford CT 06106 DOCKET NUMBER NAME OF PETITIONER ADDRESS OF PETITIONER (No., street, town, zip code) NAME OF RESPONDENT ADDRESS OF RESPONDENT (No., street, town, zip code) NAME(S) OF RESPONDENT(S) (Person(s) named in CHRO complaint) ADDRESS(ES) OF RESPONDENT(S) (No., street, town, zip code) If additional respondents are to be named, attach a separate sheet of paper. CHRO CASE NAME CHRO CASE NUMBER PETITION FOR ORDER I, the undersigned Petitioner in the above referenced Petition for Order RE: Commission on Human Rights and Opportunities and Notice of Hearing, hereby certify that a copy of the Petition and Notice of Hearing in the above referenced matter was served on the date and in the manner noted below for each of the defendants, and that I have attached the return receipts that I have received indicating the delivery of the Petition and Notice of Hearing: NAME OF RESPONDENT METHOD OF SERVICE CERTIFIED/REGISTERED DATE OF SERVICE RETURN RECEIPT NO. 1. 2. 3. 4. (If additional Respondents were served, complete a second affidavit) Dated at , Connecticut on INSERT TOWN WHERE SIGNED INSERT DATE YOU SIGN THE AFFIDAVIT OF SERVICE SIGNED PETITIONER/ATTORNEY Subscribed and sworn to before me at _________________________ this _______ day of__________________, _______. COMMISSIONER OF THE SUPERIOR COURT/NOTARY PUBLIC My Commission Expires American LegalNet, Inc. www.FormsWorkflow.com