OAO 440 (Rev. 8/01) Summons in a Civil Action UNITED STATES DISTRICT COURT Northern District of New York SUMMONS IN A CIVIL CASE V. Commissioner of Social Security CASE NUMBER: TO: (Name and address of Defendant) Office of Regional Chief Counsel, Region II Social Security Administration 26 Federal Plaza, Room 3904 New York, New York 10278-0004 YOU ARE HEREBY SUMMONED and required to serve on PLAINTIFF’S ATTORNEY (name and address) an answer to the complaint which is served on you with this summons, within days after service of this summons on you, exclusive of the day of service. If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint. Any answer that you serve on the parties to this action must be filed with the Clerk of this Court within a reasonable period of time after service. CLERK DATE (By) DEPUTY CLERK American LegalNet, Inc. www.FormsWorkFlow.com OAO 440 (Rev. 8/01) Summons in a Civil Action RETURN OF SERVICE Service of the Summons and complaint was made by me(1) DATE TITLE NAME OF SERVER (PRINT) Check one box below to indicate appropriate method of service G Served personally upon the defendant. Place where served: G Left copies thereof at the defendant’s dwelling house or usual place of abode with a person of suitable age and discretion then residing therein. Name of person with whom the summons and complaint were left: G Returned unexecuted: G Other (specify): STATEM ENT OF SERVICE FEES TRAVEL SERVICES TOTAL DECLARA TION OF SERVER I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct. Executed on Date Signature of Server Address of Server (1) As to who may serve a summons see Rule 4 of the Federal Rules of Civil Procedure. American LegalNet, Inc. www.FormsWorkFlow.com