UNITED STATES BANKRUPTCY COURT MIDDLE DISTRICT OF GEORGIA IN RE: Bankruptcy Case No. DEBTOR(S) Adv. Proceeding No. ALL DOCUMENTS REGARDING THIS MATTER MUST BE IDENTIFIED BY BOTH ADVERSARY AND BANKRUPTCY CASE NUMBERS PLAINTIFF DEFENDANT CERTIFICATE OF SERVICE OF SUMMONS IN A BANKRUPTCY CASE I, ___________________, certify that I am , and at all times during the service of process was, not less than 18 years of age and not a party to the matter concerning which service of process was made. I further certify that the service of this summons and a copy of the complaint was made on [date] ______________________ by: ___ Mail Service: Regular, first class U.S. Mail, postage fully pre-paid, addressed to: ___ Personal Service: By leaving the process with defendant or with an officer or agent of defendant at: ___ Residence Service: By leaving the process with the following adult at: ___ Publication: The defendant was served as follows: [Describe briefly] ___ State Law: The defendant was served pursuant to the laws of the State of _____ as follows: [Describe briefly] Under penalty of perjury, I declare that the foregoing is true and correct. __________________ Date _________________________ Signature Print name, business address, city, state and zip code: ___________________________ ___________________________ ___________________________ American LegalNet, Inc. www.USCourtForms.com