SUPERIOR COURT OF THE DISTRICT OF COLUMBIA Civil Division Small Claims and Conciliation Branch 510 4th Street, N.W., Court Building B, Room 120, Washington, D.C. 20001 Telephone Number: (202) 879-1120 Website: www.dccourts.gov CV-479 / Mar. 2018 Super. Ct. Sm. Cl. R. 2, 4 Case No. Plaintiff Defendant vs. Address Address New address for service AFFIDAVIT OF SERVICE BY PRIVATE INDIVIDUAL ACTING AS SPECIAL PROCESS SERVER I, , am competent, at least 18 years of age, and I reside or work at . I am not a party and have no interest in this case. 1. On , 20, at a.m. / p.m. I served a copy of the statement of claim, verification, notice, and any attachments and if applicable, the order granting an extension of time to serve Defendant, notice of the next hearing date, and any other order directed by the court in the following manner (check one): On the Defendant personally at . By leaving the materials described above with , a person of suitable age and discretion, who resides with Defendant at . (For a corporation, partnership, or association) I served , who is (check one of the following): an officer a managing or general agent an agent authorized by appointment or law to receive service of process, at . 2. You must set forth specific facts from which the Court can determine that process was served as indicated above and in compliance with Super. Ct. Sm. Cl. R. 4, including a physical description (for example: approximate age, height, weight, etc.) of any person who was served: Special Process Server (Print Name and Sign) Subscribed and sworn to before me this day of , 20. Notary Public / Deputy Clerk My commission expires NOTE: A separate Affidavit is required for service on each named Defendant American LegalNet, Inc. www.FormsWorkFlow.com