NHJB-2067-F (08/01/2015) Page 1 of 1 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF RECEIPT OF SERVICE For: Petition for Divorce Petition for Legal Separation Petition for Civil Union Dissolution Parenting Petition Other: I, , do hereby state under oath that I received the petition specified above and the: Notice to Spouse Notice to Parties Notice to Co Respondent Appearance Notice of Post-Decree Action Checklist for Rule 1.25-A Child Impact Program Notice UCCJEA Affidavit Have you considered Mediation? Motion Notice (Fill in type of notice) Date Signature Phone Number: Address: State of , County of This instrument was acknowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title American LegalNet, Inc. www.FormsWorkFlow.com