Fill and Sign the Washington Dc Healthcare Systems Inc and Jeffrey Thompson Form

CA 1-A [Rev. June 2017] Super. Ct. Civ. R. 4 Wa shington, D.C. 20001 Telephone: 879 -1133 SUPERIOR COURT OF THE DISTRICT OF COLUMBIA CIVIL DIVISION - Civil Actions Branch 500 Indiana Avenue, N.W., Suite 5000 Washington, D.C. 20001 Telephone: (202) 879- 1133 Website: www.dccourts.gov ______________________________ Plaintiff(s) v. _________ _____________________ Defendant(s) Case No: ______________________ NOTICE AND ACKNOWLEDG MENT OF SERVICE To (insert name and address of the party to be served) : ________________________________ ________________________________ ________________________________ ________________________________ The enclosed summons, complaint, initial order , and any addendum are served in accordance with Superior Court Rule of Civil Procedure 4(c)(5). Please sign and date the Acknowledgement at the bottom of the page . If you are served on behalf of a corporation, unincorporated association (including a partnership), or other entity, please indicate your relationship to that entity in the space beside your signature. If you are served on behalf of another person and y ou are authorized to rec eive process, please indicate your authority in the space beside your signature . If you do not complete and return the form to the sender within 21 days after it was mailed and you do not show good cause for this failure , you (or the party on whose behalf you are being served) will be required to pay 1) the costs incurred in serving the summons, complaint , initial order, and any addendum in any other manner permitted by law and 2) the reasonable expenses, including attorney’s fees, for any motion required to collect those service expenses . If you do complete and retu rn this form, you (or the party on whose behalf you are being served) must answer the complaint within 2 1 days after you have signed, dated, and returned the form (or wi thin 60 days if the party being served is the United States, the District of Columbia, or officers or employees of either) . If you fail to do so, judgment by default may be entered against you for the relief demanded in the complaint. This Notice and Ackn owledgment of Receipt of Summons, Complaint, Initial Order, and Any Addendum w as mailed on (insert date) : __________________. ________________________________ Signature ________________________________ Date of Signature ACKNOWLEDGMENT OF RECEIPT OF SUMM ONS, COMPLAINT, INITIAL ORDER, AND ANY ADDENDUM I (print name) ______________________________ received a copy of the summons, complaint, initial order , and any addendum in the above captioned matter at (insert address): ____ ___________________________ ________ _______________________ _______________________________ _____________________________ _____________________________ ____________________ Signature Relationship to Defendant/Authority Date of Signature to Receive Service Para pedir una traducción, llame al (202) 879 -4828 如需翻译,请打 电话 (202) 879- 4828 Veuillez appeler au (202) 879- 4828 pour une traduction Để có m ột bài d ịch, hãy gọ i (202) 879 -4828 የአማርኛ ትርጉም ለማግኘት (202) 879- 4828 ይደውሉ 번역을 원하시면 , (202) 879- 4828 로 전화주십시요