FORM NO. 4 (LF004) UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF TENNESSEE _______________________________________________________________________________________________ In re Case No. Chapter Debtor(s)*. Social Security No.: (H) (W) Employer Tax I.D. No.: ________________________________________________________________________________________________ SUMMONS TO DEBTOR IN INVOLUNTARY CASE ________________________________________________________________________________________________ To the above named debtor(s): A petition under title 11, United States Code, was filed against you on _________________________(date) in this Bankruptcy Court requesting an order for relief under chapter ___________ of the Bankruptcy Code (title 11 of the United States Code). YOU ARE SUMMONED and required to submit to the Clerk of the Bankruptcy Court a motion or answer to the petition within 20 days after the service of this summons. A copy of the petition is attached. Address of Clerk: Jed G. Weintraub, Clerk of Court United States Bankruptcy Court 111 S. Highland, Room 107 Jackson, TN 38301 At the same time you must serve a copy of your motion or answer on petitioner’s attorney. Name and Address of Petitioner’s Attorney: If you make a motion, your time to serve an answer is governed by FED. R. BANKR. P. 1011(C). If you fail to respond to this summons, the order for relief will be entered. JED G. WEINTRAUB Clerk of the Bankruptcy Court Date:_______________________ By:___________________________________________________ Deputy Clerk CERTIFICATE OF SERVICE * Set forth all names, including trade names, used by the debtor within the last six years. FED. R. BANKR. P. 1005). For joint debtors, set forth both social security numbers. American LegalNet, Inc. www.USCourtForms.com FORM NO. 4 (LF004) 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: 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