New York Affidavit of Service Form

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SUPREME COURT OF THE STATE OF NEW YORK

1 COUNTY OF

——————————————————————–X

2

3 Plaintiff, Index No.:

-against-

AFFIDAVIT OF SERVICE

4 Defendant.

——————————————————————-X

5 STATE OF }

ss:

COUNTY OF }

6 ______________________________ being duly sworn, says:

7 1. I am not a party to the action, am over 18 years of age and reside at:

________________________________________________________________________

8 2. On__________________, at ____a.m./p.m. at ________________________________

_________________________________________ I served the . summons with

notice OR . summons and verified complaint, and the notice of automatic orders,

on ____________________________, the Defendant named by delivering a true

copy to the Defendant personally.

. In addition I served a copy of the Child Support Standards Chart.

. In addition I served a copy of the Notice of Continuation of Health Care Coverage

3. The notice required by the Domestic Relations Law, Section 232 — “ACTION FOR A

DIVORCE” — was legibly printed on the face of the summons served on the Defendant.

9 4. I knew the person so served to be the person described in the summons as the Defendant.

My knowledge of the Defendant and how I acquired it is as follows: (select one)

. I have known the defendant for _______ years and____________________

__________________________________________________________________

__________________________________________________________________

OR

. I identified the Defendant by a photograph annexed to this affidavit and which was

given to me by the Plaintiff.

OR

. Plaintiff accompanied me and pointed out the Defendant.

OR

. I asked the person served if he/she was the person named in the summons and

Defendant admitted being the person so named.

(Form UD-3 – Rev. 9/11)

5. Deponent describes the individual served as follows:

Sex Height Weight Age Color of Skin Color of Hair

. Male

. Female

. Under 5’

. 5’0”-5’3”

. 5’4”-5’8”

. 5’9”-6’0”

. Over 6′

. Under 100 Lbs.

. 100-130 Lbs.

. 131-160 Lbs.

. 161-200 Lbs.

. Over 200 Lbs.

. 14-17 Yrs.

. 18-20 Yrs.

. 21-35 Yrs.

. 36-50 Yrs.

. 51-65 Yrs.

. Over 65 Yrs.

Describe color:

____________

____________

____________

____________

. Black

. Brown

. Blond

. Gray

. Red

. White

. Balding

. Bald

Other identifying features, if any:___________________________________________________.

10 . 6a. At the time I served the Defendant, I asked him/her if he/she was in the military service of this

state, any other state, or this nation, and the Defendant responded in the negative.

.6b. The Defendant stated that he/she is in the following military service .

.6c. The Defendant refused to answer.

11 ______________________________

Server’s Signature

Subscribed and Sworn to

before me on

NOTARY PUBLIC

(Form UD-3 – Rev. 9/11)