Fill and Sign the Affidavit for Service of Process on the Secretary Form

AFFIDAVIT FOR SERVICE OF PROCESS ON THE Case No. .............................................................................................. SECRETARY OF THE COMMONWEALTH Commonwealth of Virginia Va . Code §§ 8.01-301, -329; 55-218.1; 57-51 ......................................................................................................................................................................................... District Court .............................................................................................................................. v. .................................................................................................................................... .............................................................................................................................. .................................................................................................................................... .............................................................................................................................. .................................................................................................................................... TO THE PERSON PREPARING THIS AFFIDAVIT: You must comply with the appropriate requirements listed on the back of this form. Attachments: [ ] Warrant [ ] Motion for Judgment [ ] ............................................................................................................................................................... I, the undersigned Affiant, state under oath that: [ ] the above-named defendant [ ] .......................................................................................................................................................................................................... whose last know n address is: [ ] same as above [ ] ............................................................................................................................................................................ ......................................................................................................................................................................................................................................................................................... 1. [ ] is a non-resident of the Commonwealth of Virginia or a foreign corporation and Vir ginia Code § 8.01-328.1(A) ..................................... applies (see NON-RESIDENCE GROUNDS REQUIREMENT on reverse). 2. [ ] is a person whom the party seeking serv ice, after exercising due diligence, has been unable to locate (see DUE DILIGENCE REQUIREMENT on reverse) and that is the return date on the attached warrant, motion for judgment or notice (see TIMELY SERVICE REQUIREMENT on reverse). ....................................................................... _____________________________________________________ DATE [ ] PARTY [ ] PARTY’S ATTORNEY [ ] PARTY’S AGENT State of .............................................................................................................. [ ] City [ ] County of .................................................................................................... Acknowledged, subscribed and sworn to before me this ............................... day of .................................................................................... , 20 ........................... ....................................................................... ___________________________________________________________________________ NOTARY REGISTRATION NUMBER [ ] CLERK [ ] MAGISTRATE [ ] NOTARY PUBLIC (My commission expires ................................) [ ] Verification by the clerk of the court of the date of filing of the certificate of compliance requested. A self-addressed stam ped envelope was provided to the clerk at the time of filing of this Affidavit. NOTICE TO THE RECIPIENT from the Office of the Exec utive Secretary of the Commonwealth of Virginia: You are being served with this notice and attached pleadings under Section 8.01-329 of the C ode of Virginia which designates the Secretary of the Commonwealth as statutory agent for Service of Process. The Secretary of the Commonwealth’s ONLY responsibility is to mail, by certified mail, return receipt requested, the enclosed papers to you. If you have any questions concerning these documents, you may wish to seek advice from a lawyer. SERVICE OF PROCESS IS EFFECTIVE ON THE DATE WH EN SERVICE IS MADE ON THE SECRETARY OF THE COMMONWEALTH. CERTIFICATE OF COMPLIANCE I, the undersigned, Clerk in the Office of the Secret ary of the Commonwealth, hereby certify the following: 1. On .............................................................................................................. , legal service in the above-styled case was made upon the Secretary of the Commonwealth, as statutory agent for persons to be served in accordance with Section 8.01-329 of the Code of Virginia, as amended. 2. On .............................................................................................................. , papers described in the Affidavit and a copy of this Affidavit were forwarded by certified mail, return receipt requested, to the party designated to be served with process in the Affidavit. _______________________________________________________________________ SERVICE OF PROCESS CLERK, DESIGNATED BY THE AUTHORITY OF THE SECRETARY OF THE COMMONWEALTH FORM DC-410 FRONT 07/13 FORM DC-410 REVERSE 11/07 TIMELY SERVICE REQUIREMENT: Service of process in actions brought on a warrant or motion for judgment pursuant to Virginia Code § 16.1- 79 or § 16.1-81 shall be void and of no effect when such service of process is received by the Secretary within ten days of any return day set by the warrant. In such cases, the Secretary sh all return the process or notice, the copy of the affidavit, and the prescrib ed fee to the plaintiff or his agent. A copy of the notice of the rejection shall be sent to the clerk of the court in which the action was filed. NON-RESIDENCE GROUNDS REQUIREMENT: If box number 1 is checked, insert the appropriate subsection number: A court may exercise personal jurisdicti on over a person, who acts directly or by an agent, as to a cause of action arising from the person’s: 1. Transacting any business in this Commonwealth; 2. Contracting to supply services or things in this Commonwealth; 3. Causing tortious injury by an act or omission in this Commonwealth; 4. Causing tortious injury in this Commonwealth by an act or omission outside this Commonwealth if he regularly does or solicits business, or engages in any other persistent course of conduct, or derives substantial revenue from goods used or consumed or services rendered in this Commonwealth; 5. Causing injury in this Commonwealth to any pers on by breach of warranty expressly or impliedly made in the sale of goods outside this Commonwealth when he might reasonably have expected such person to use, consume, or be affected by the goods in this Commonwealth, provided that he also regularly does or solicits business, or engages in a ny other persistent course of conduc t, or derives substantial revenue from goods used or consumed or serv ices rendered in this Commonwealth; 6. Having an interest in, using, or possessi ng real property in this Commonwealth; 7. Contracting to insure any pers on, property, or risk located within the Commonwealth at the time of contracting; or 8. (ii). Having been ordered to pay spousal support or child support pursuant to an order entered by any court of competent jurisdiction in this Commonwealth having in pe rsonam jurisdiction over such person. 9. Having incurred a liability for taxe s, fines, penalties, interest, or other charges to any political subdivision of the Commonwealth. DUE DILIGENCE REQUIREMENT: If box number 2 is checked, th e following provision applies: When the person to be served is a resident, the signatur e of an attorney, party or agent of the person seeking service on such affidavit shall constitute a certificate by him that process has been delivered to the sheriff or to a disinterested person as permitted by § 8.01-293 for executio n and, if the sheriff or disinterested person was unable to execute such service, that the person seeking service has made a bona fide attempt to determine the actual place of abode or locati on of the person to be served.