AO 440 (Rev. 02/09) Summons in a Civil Action UNITED STATES DISTRICT COURT for the Northern District of New York ) ) ) ) ) Plaintiff v. Defendant Civil Action No. SUMMONS IN A CIVIL ACTION To: (Defendant's name and address) Office of General Counsel Region II, SSA 26 Federal Plaza, Room 3904 New York, NY 10278-0004 A lawsuit has been filed against you. Within 20 days after service of this summons on you (not counting the day you received it) -- or 60 days if you are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ. P. 12 (a)(2) or (3) -- you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff's attorney, whose name and address are: If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. You also must file your answer or motion with the court. Date Signature of Clerk _______________________________ Signature of Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com AO 440 (Rev. 02/09) Summons in a Civil Action (Page 2) Civil Action No. PROOF OF SERVICE (This section should not be filed with the court unless required by Fed. R. Civ. P. 4(1)) This summons for (name of individual and title, if any) was received by me on (date) . u I personally served the summons on the individual at (place) on (date) u I left the summons at the individual's residence or usual place of abode with (name) , a person of suitable age and discretion who resides there, on (date) , and mailed a copy to the individual's last known address; or , who is on (date) u I returned the summons unexecuted because u Other (specify): . My fees are $ for travel and $ for services, for a total of $ 0.00 ; or u I served the summons on (name of individual) designated by law to accept service of process on behalf of (name of organization) ; or ; or . I declare under penalty of perjury that this information is true. Date: Server's signature Printed name and title Server's address Additional information regarding attempted service, etc: American LegalNet, Inc. www.FormsWorkFlow.com