AFFIDAVIT OF SERVICE PETITION FOR ORDER RE: COMMISSION ON HUMAN RIGHTS AND OPPORTUNITIES AND NOTICE OF HEARING JD-CV-69 Rev. 10-15 C.G.S. § 46a-82e(d) STATE OF CONNECTICUT SUPERIOR COURT 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 no later than five days after service was made. The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. ADA Notice 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, 95 Washington Street, Hartford, CT 06106 Name of petitioner Name of respondent Docket number Address of petitioner (Number, street, town, zip code) Address of respondent (Number, street, town, zip code) COMMISSION ON HUMAN RIGHTS & OPPORTUNITIES CHRO Case name 25 SIGOURNEY STREET, HARTFORD, CT 06106 CHRO Case number Affidavit of Service I, the undersigned Petitioner in the above referenced Petition for Order RE: Commission on Human Rights and Opportunities and Notice of Hearing, 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 Number 1. 2. 3. 4. (If additional Respondents were served, complete a second affidavit) Dated at SIGNED Insert town where signed , Connecticut on Insert date you sign the affidavit of service 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