IN THE DISTRICT COURT OF WYANDOTTE COUNTY, KANSAS CIVIL COURT DEPARTMENT IN THE MATTER OF: _______________________________________ Petitioner and CASE NO:___________________ DIVISION NO:_______________ CHAPTER 60 _______________________________________ Respondent RETURN OF SERVICE FOR CERTIFIED MAIL STATE OF KANSAS) COUNTY OF WYANDOTTE) The undersigned pro se litigant being duly sworn, states: I have served a Motion for __________________________ on the(Petitioner/Respondent/attorney of record) and the following Return for Receipt of Service was served by certified mail on_____________________(date) and place as listed on the attached green card. Here is where you will attach the green card once you have received it back by mail from the post office showing that someone has signed for the certified letter. _________Check here (if appropriate) service by certified mail was refused. ________________________________ Your Signature Pro Se Subscribed and sworn to before me on this __________day of ___________________________ My appointment expires: ________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com