STATEMENT OF SERVICE (DELIVERY) 226 SMALL CLAIMS JD-CV-123 Rev. 4-19 P.B. 247 24-10Instructions If filed on paper, fill out one (1) form for each defendant. Attach all documents showing how the Small Claims Writ and Notice of Suit (form JD-CV-40) and related documents were served on (delivered to) the defendant, and check the box below that applies. Keep all receipts showing how much you paid to have the Small Claims Writ and Notice of Suit and related documents served on the defendant. If filed electronically, follow the instructions above and ensure that you select the appropriate name of the document you are filing. For service on (delivery to) the defendant: (Write name of defendant above)The Small Claims Writ and Notice of Suit (form JD-CV-40) and related documents, if any, were served on (delivered to) the defendant named above by:(Check the box that applies)1.) priority mail with delivery confirmation; delivery confirmation is attached. I paid $ for this, or2.) certified mail, return receipt requested, or with electronic delivery confirmation; signed return receipt, or electronic for this, or3.) a nationally recognized courier service providing delivery confirmation; tracking information showing delivery for this, or4.) a proper officer in the manner in which a writ of summons is served in a civil action; officer's return of serviceis attached. I paid $filed with the court. STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Date signed Print name Signed (Plaintiff or plaintiff's representative)I paid $delivery confirmation, is attached. ADA NOTICE 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 COURT USE ONLY SMRSOS *SMRSOS* American LegalNet, Inc. www.FormsWorkFlow.com