KITSAP COUNTY DISTRICT COURT, STATE OF WASHINGTON __________________________________________, Plaintiff, vs. __________________________________________, Defendant. NO. RETURN OF SERVICE (Small Claims) ________________________________________________ states truthfully on oath and certifies or declares under penalty of perjury, under the laws of the State of Washington, that the following is true and correct: 1. I am a United States citizen, over 18 years of age and neither a party nor a witness to the action named above. 2. I served ________________________________________________ with the Notice of Claim. A true and correct copy of the Notice of Claim is attached hereto as a part of this affidavit. 3. Date and time of service: _____________________________ _____________________ a.m./p.m. Date of Service 4. Time of Service Place of Service: __________________________________________________________________ Address __________________________________________________________________ City 5. State Zip Service was made as indicated below: By delivery to the person named above. By leaving a copy at the house of the usual abode of the person named at (2) above, with _________________________, a person of suitable age and discretion then resident therein. If suit is against a company or corporation, by delivery to the person named at (2) above, whose position or title in the company or corporation is _____________________________. I mailed a copy of the Notice of Claim to the above defendant, and the certified mail return receipt with signature of party being served is attached. I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Date Place Affiant Signature _________________________________________ Affiant (Print/Type) Revised 3/08/11 American LegalNet, Inc. www.FormsWorkFlow.com