Circuit Court for Case No. City or County vs. Name Name Apt. # Street Address City State Zip Code Area Code Apt. # Street Address Telephone City State Plaintiff Area Code Zip Code Telephone Defendant AFFIDAVIT OF SERVICE (Private Process) (DOM REL 55) I certify that I served at a.m./ Name of person served on , Time , at Date , , Street Address City p.m. Check one , State , Zip Code a copy of the following documents (Check all that apply): Writ of summons Complaint/Petition/Motion: List name of complaint/petition/motion Domestic Case Information Report (DCIR Form) Financial Statement Show Cause Order and Petition: List type of petition Other: List all other documents served which were previously filed with this Court. Attached is a copy of any summons ("process") issued by the Court, the original of which I served upon the person served. Service was made in the following manner: The person I left the papers with acknowledged being: (1) a resident of the above -listed address; (2) 18 years of age or older; (3) of suitable age and discretion in that the relationship to the defendant is and that; (4) the above-listed address is the defendant's residence or usual place of abode. Description of Defendant/Person Served: Race Sex Height Weight Age I certify that I am over eighteen (18) years of age and I am not the Plaintiff or the Defendant. I SOLEMNLY AFFIRM under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information, and belief. Date Name of Server (signature) Name of Server (printed or typed) Street Address, City, State, Zip Code of Server ( CC-DR 55 (Rev. 3/2008) ) Area Code Telephone Number of Server American LegalNet, Inc. www.FormsWorkflow.com