United States District Court for the Southern District of New York Civil Action, File
            Number
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | A.B., Plaintiff | Notice and Acknowledgment of Receipt of Summons and Complaint | 
                  
                     
                     | v. |   | 
                  
                     
                     | C. D., Defendant |   | 
               
            
          
          
         NOTICE
         TO: (insert the name and address of the person to be served.)
         The enclosed summons and complaint are served pursuant to Rule 4(c)(2)(C)(ii) of the
            Federal Rules of Civil Procedure.
         
         You must complete the acknowledgment part of this form and return one copy of the
            completed form to the sender within 20 days. You must sign and date the acknowledgment.
            If you are served on behalf of a corporation, unincorporated association (including
            a partnership), or other entity, you must indicate under your signature your relationship
            to that entity. If you are served on behalf of another person and you are authorized
            to receive process, you must indicate under your signature your authority. If you
            do not complete and return the form to the sender within 20 days, you (or the party
            on whose behalf you are being served) may be required to pay any expenses incurred
            in serving a summons and complaint within 20 days. If you fail to do so, judgment
            by default will be taken against you for the relief demanded in the complaint. I declare,
            under penalty of perjury, that this Notice and Acknowledgment of Receipt of Summons
            and Complaint was mailed on (insert date).
         
                                                               
                                          Signature
                                                               
                                          Date of Signature
          
          
         ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT
         I declare, under penalty of perjury, that I received a copy of the summons and of
            the complaint in the above-captioned manner at (insert address).
         
                                                               
         Signature
         Relationship to Entity/Authority to Receive Service of Process
                                                               
         Date of Signature