Close Close

Clerk Handbooks
Supreme Court Rules



Section/Rule:
No. 4C

Subject:
Forms - Rules of Civil Procedure - Civil Procedure Forms
Publication / Adopted Date:
September 28, 1993

Topic:
Notice and Acknowledgement for Service By Mail - Chapter 517 Cases
Revised / Effective Date:
January 1, 1994
FORM NO. 4-C.

(CHAPTER 517 CASES)
NOTICE AND ACKNOWLEDGMENT FOR SERVICE BY MAIL
CIRCUIT FOR __________ COUNTY
DIVISION __________

Civil Action, File Number

A.B.,                                )
                                     )
       Plaintiff,                    )
                                     )
vs.                                  )
                                     )
C.D.,                                )
                                     )
       Defendant.                    )

NOTICE


TO: (Insert the name and address of the person to be served)
The enclosed summons and petition are served pursuant to Missouri Supreme Court Rule 54.16.
You may sign and date the acknowledgment part of this form and return one copy of the completed form to the sender within thirty days of __________________.
(insert date of mailing)

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 thirty 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 petition in any other manner permitted by law.

If you do complete and return this form, you or the party on whose behalf you are being served must comply with the requirements of the summons. If you fail to do so, judgment by default may be taken against you for the relief demanded in the petition.

I DECLARE, UNDER PENALTY OF PERJURY, THAT THIS NOTICE WAS MAILED ON

_________________.
(insert the date)

___________________________________
Signature

ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND PETITION

I declare, under penalty of filing a false affidavit, that I received a copy of the Summons and of the Petition in the above captioned matter.

___________________________________
Signature

___________________________________
Relationship to Entity/Authority
Receive Service of Process

___________________________________
Date Signed

(Adopted Sept. 28, 1993, eff. Jan. 1, 1994.)