Cert of Svc re Smns to Debtor in Inv. Case lf004cert (1/16/04) UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF TENNESSEE ________________________________________________________________________________________________________ In re Case No. Chapter 13 Debtor(s). ________________________________________________________________________________________________________ CERTIFICATE OF SERVICE RE SUMMONS TO DEBTOR IN INVOLUNTARY CASE _______________________________________________________________________________________________ I, ________________________________________________(Name), certify that I am, and at all times during the service of process was, not less than 18 years of age and not a party to the matter concerning which service of process was made. I further certify that the service of this summons and a copy of the petition was made _______________________________________(date) by: Mail service: Regular, first class United States mail, postage fully pre-paid, addressed to: Electronic Service (in a manner consistent with F.R.C.P. 5(b)(2)(D): Personal service: By leaving the process with defendant or with an officer or agent of defendant at: Residence Service: By leaving the process with the following adult at: Publication: The defendant was served as follows: [Describe briefly] State Law: The defendant was served pursuant to the laws of the State of ______________________________________ (name of state) as follows: [Describe briefly] Under penalty of perjury, I declare the foregoing to be true and correct. _____________________________ ___________________________________________ Date Signature Print Name _____________________________________________________________________ Business Address _____________________________________________________________________ City State Zip American LegalNet, Inc. www.USCourtForms.com