IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of the Marriage of: , Petitioner, and , Respondent. STATE OF ) ) ) ) ) ) ) ) ) ) Case No. ACCEPTANCE OF SERVICE ) )ss. ) County of I, , being first duly sworn, say: I am the Respondent in this matter and on I received a true copy of the Petition and Summons, with attached notices of statutory restraining order preventing dissipation of assets, continuation of health coverage, Notice of CIF Filing, mediation and other information provided by the court clerk in the County of , State of . Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to for assistance in preparing this form. Signature of Respondent Address or Contact Address Print Name City, State, Zip SIGNED AND SWORN to before me this by Telephone or Contact Telephone day of , 20 . Notary Public for My Commission Expires: ACCEPTANCE OF SERVICE - Page 1 of 1 Disso-1BC: AccServ1BCVer03.doc (9/10) , /Court Clerk American LegalNet, Inc. www.FormsWorkFlow.com