of service

I, [Your Name], being duly sworn, depose and say:

I am over the age of eighteen (18) and not a party to the action herein. My address is [Your Address].

On 31.12.1969 klo 16.00[Time], I served the following documents:

[List documents, e.g., "Summons and Complaint"]
[Any additional documents, if applicable]
The documents were served upon [Name of the Person Served], who is a [relationship to defendant, e.g., "defendant", "agent", etc.], at the following location:
[Address where service occurred]

I made the service in the following manner:

[Describe how the service was made, e.g., "By handing the documents directly to the individual", "By leaving the documents with a person of suitable age and discretion at the premises", etc.]
At the time of service, I observed that the individual served was [description of the person, e.g., "over the age of eighteen (18)", "was the appropriate party", etc.].

I certify under penalty of perjury that the foregoing is true and correct.

Executed on .