Fill and Sign the I the Undersigned Affiant State under Oath that Form

AFFIDAVIT FOR SERVICE OF PROCESS ON THE Case No. ................................................................................ SECRETARY OF THE COMMONWEALTH Commonwealth of Virginia VA. CODE §§ 8.01-301, -310, -329; 55-218.1; 57-51 ................................................................................................................................................................................................................................. Circuit Court ..................................................................................................................... v. ..................................................................................................................... ..................................................................................................................... ......... ............................................................................................................ ..................................................................................................................... ..................................................................................................................... TO THE PERSON PREPARING THIS AFFIDAVIT : You must comply with the appropriate requirements listed on the back of this form. I, the undersigned Affiant, state under oath that [ ] the above-named defendant [ ] .......................................................................................................................................................................... whose last known 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 page 2). 2. [ ] is a person whom the party seeking serv ice, after exercising due diligence, has been unable to locate (see DUE DILIGENCE REQUIREMENT ON BACK) is the hearing date and time on the attached process or notice (if applicable). ................................................................. ___________________________________________________________________________________________ DATE [ ] PARTY [ ] PARTY’S ATTORNEY [ ] PARTY’S AGENT [ ] PARTY’S REGULAR AND BONA FIDE EMPLOYEE State of ........................................................ [ ] City [ ] County of ............................................................................................................................. Acknowledged, subscribed and sworn to before me this day by ............................................................................................................................. PRINT NAME OF SIGNATORY ................................................................. ______________________________________________________________________ DATE [ ] CLERK [ ] MAGISTRATE [ ] NOTARY PUBLIC Notary Registratio n No. ......................................... My commission expires: ................................ [ ] Verification by the clerk of court of the date of filing of th e certificate of compliance is requested. A self-addressed stampe d envelope was provided to the clerk at the tim e of filing this Affidavit. NOTICE TO THE RECIPIENT from the Office of th e Secretary of the Commonwealth of Virginia: You are being served with this notice and attached pleadings under Section 8.01-329 of the Code 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 ma il, 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 WHEN SE RVICE IS MADE ON THE SECRETARY OF THE COMMONWEALTH. CERTIFICATE OF COMPLIANCE Attachments: [ ] Summons and Complaint [ ] Notice [ ] ......................................................................................................... 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 cas e was made upon the Secretary of the Commonwealth, as statutory agent for persons to be served in acco rdance with Section 8.01-329 of the Code of Virginia, as amended. 2. On ................................................................................................... , papers described in the Affidavit and a co py of this Affidavit were forwarded by certified mail, return receipt requested, to the party de signated to be served with process in the Affidavit. _______________________________________________________________________ SERVICE OF PROCESS CLERK, DESIGNATED BY THE AUTHORITY OF THE SECRETARY OF THE COMMONWEALTH FORM CC-1418 (MASTER, PAGE ONE OF TWO) 07/13 NON-RESIDENCE GROUNDS REQUIREMENT: If box number 1 is checked, insert the appropriate subsection number: A court may exercise personal jurisdic tion 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 person 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 any other persistent course of conduct, or derives substantial revenue from goods used or consumed or services rendered in this Commonwealth; 6. Having an interest in, using, or possessi ng real property in this Commonwealth; 7. Contracting to insure any person, property, or risk located within this Commonwealth at the time of contracting; 8(ii). Having been ordered to pay s pousal support or child support pursuant to an order entered by any court of competent jurisdiction in this Commonwealth having in personam jurisdiction over such person; or 10. Having incurred a liability for taxes, 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 been un able, after exercising due diligence, to locate the person to be served. FORM CC-1418 (MASTER, PAGE TWO OF TWO) 11/07