Case 1:18-mi-99999-UNA Document 4142 Filed 12/27/18 Page 1 of 11

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF GEORGIA
ATLANTA DIVISION

OFFICE OF THE FULTON )

COUNTY DISTRICT ATTORNEY )
Plaintiff, )
v. ) CIVIL ACTION NUMBER:
UNITED STATES DEPARTMENT )
OF JUSTICE, an agency of the )
United States, )
Defendant. )

COMPLAINT FOR DECLARTORY AND INJUNCTIVE RELIEF

(FREEDOM OF INFORMATION ACT)

Having been stymied for more than 600 days from receiving any documents

from the Department of Justice related to the shooting of Jamarion Robinson,

Plaintiff Office of the Fulton County District Attorney (“Plaintiff” or “the District

Attorney”) brings this action against Defendant United States Department of Justice

(“Defendant” or “the DOJ”) to compel compliance with the Freedom of Information

Act, 5 U.S.C. § 552 (“FOIA”). As grounds therefor, Plaintiff alleges as follows:

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JURISDICTION AND VENUE

1. The Court has jurisdiction over this action pursuant to 5 U.S.C. §

552(a)(4)(B) and 28 U.S.C. § 1331.

2. Venue is proper in this district pursuant to 28 U.S.C. § 1391(e).

PARTIES

3. Plaintiff is a state government office charged with the investigation and

prosecution of all felony violations of Georgia law that occur within Fulton County,

Georgia (Atlanta Judicial Circuit). The District Attorney prosecutes all indictable

offenses, as well as those that may be charged by accusation, and litigates these

offenses in both the trial and appellate courts of the State of Georgia.

4. The DOJ is an agency of the U.S. Government and is headquartered in

Washington, DC. The DOJ has possession, custody, and control of records to which

Plaintiff seeks access.

FACTS

5. On August 5, 2016, 14 law enforcement officers from eight separate

local municipal police departments, along with at least one United States Marshal,

traveled to the Parkside Camp Creek Luxury Apartments in Atlanta, Georgia to

execute a State of Georgia arrest warrant for Jamarion Robinson (hereinafter “Mr.

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Robinson”). The state arrest warrant alleged that Mr. Robinson committed an

aggravated assault in violation of Georgia Code Annotated 16-5-21, a state crime.

Mr. Robinson was not charged with any federal crime, and there was not a federal

arrest warrant pending for Mr. Robinson.

6. Based upon several “Memorand[a] of Understanding” (hereinafter

“MOUs”) between the United States Marshals Service (a component of DOJ) and

local municipal law enforcement agencies, the local municipal officers executing the

state arrest warrant purported to be members of a federal task force. (See Exhibit

“A”). However, Plaintiff has not received any documentation showing that the

officers were specifically instructed or permitted to conduct Mr. Robinson’s arrest

under the auspices of a federal task force. Moreover, pursuant to the evidence so

far uncovered, the decision to conduct the arrest appears to have been initiated and

directed by officers from the local agencies. Additionally, the MOUs specifically

state that officers “will comply with their agencies’ guidelines concerning the use of

firearms [and] deadly force … .” (See Exhibit “A”).

7. At the time of the execution of the state arrest warrant, Jamarion

Robinson was a 26-year-old male student and football player at Clark Atlanta

University, who was in the process of transferring to Tuskegee University in

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Alabama as a student-athlete. With the exception of a traffic violation, Mr. Robinson

had no criminal convictions.

8. Mr. Robinson had also been recently diagnosed as a schizophrenic.

Prior to effectuating the state arrest warrant on Mr. Robinson, the officers involved

in making the arrest were informed of Mr. Robinson’s diagnosis. Despite this

knowledge, there is no evidence that the officers took his condition into

consideration when planning his capture.

9. Further, there is no evidence that the officers attempted to secure the

peaceful surrender of Mr. Robinson. Although contact was made with Mr.

Robinson’s family within 48 hours of this incident, the officers made no effort to

enlist their assistance in obtaining Mr. Robinson’s peaceful surrender. Likewise, no

efforts were made to engage the assistance of Mr. Robinson’s friends in securing a

non-violent outcome.

10. Additionally, the officers failed to secure a search warrant or seek

consent from the third-party tenant to enter the apartment unit where officers

believed Mr. Robinson to be located. Although the officers conducted over two

hours of surveillance at the apartment complex, giving them ample time to secure

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lawful entry, the officers failed to obtain a search warrant or to gain consent to enter

the apartment.

11. Before entering the apartment, the officers also failed to positively

determine that Mr. Robinson was inside. The officers did not enlist the help of the

third-party tenant who was present inside the apartment within hours of the shooting

and who left the apartment in full view of the officers while they were conducting

surveillance. The officers failed to engage or communicate with the third-party

tenant to gain consent to enter, to determine whether Mr. Robinson was indeed inside

the apartment, to determine the mental state of Mr. Robinson, or to gain assistance

in negotiating Mr. Robinson’s peaceful surrender.

12. There is also no indication that there were exigent circumstances that

would have permitted the officers to enter the apartment without consent or a search

warrant. There was no evidence at the time that Mr. Robinson had a weapon or that

he presented any threat to the officers from his location inside the apartment.

13. Nonetheless, the officers knocked down the door to the apartment and

immediately commenced firing approximately 51 shots from outside into the

apartment without any known provocation and with reckless disregard for the safety

of anyone else in the apartment and surrounding apartment units.

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14. The officers then entered the apartment and fired approximately 41

additional shots from weapons, including a 9mm submachine gun, a .40mm

submachine gun, and a .40 Glock pistol.

15. The officers fired over 90 rounds into or inside the apartment. At the

conclusion of the shooting, a firearm was located, which the officers claimed that

Mr. Robinson fired at them three times. However, when the firearm was recovered,

it was damaged and inoperable. Moreover, in an investigative report completed by

Officer Steve Schreckengost, he did not state that the officers entered the premises

because Mr. Robinson was shooting. Rather, Officer Schreckengost claims they

entered to protect others inside the apartment from Mr. Robinson, although it was

clear from their surveillance no one else was in the apartment. (See Exhibit B).

16. The medical examiner recorded over 59 entry wounds into Mr.

Robinson’s body. Without the documents requested, described herein, there is a

question as to whether Mr. Robinson’s killing was justified.

17. In the years that have followed Mr. Robinson’s death, the DOJ has

steadfastly refused to produce records related to this homicide.

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18. And the DOJ’s recalcitrance is not due to a lack of effort. More than

600 days ago, Plaintiff first sought records, such as the personnel files and training

materials of the officers responsible for Mr. Robinson’s killing.

19. DOJ has denied the requests of the Office of Fulton County District

Attorney—the one office responsible for the investigation and prosecution of state

crimes committed in Fulton County.

20. Plaintiff has attempted, multiple times, to modify its requests and work

with the DOJ to obtain these materials. The DOJ has steadfastly blocked Plaintiff

from conducting its work.

21. Faced with repeated opposition, Plaintiff submitted a FOIA request for

records. Plaintiff’s first request was made on September 6, 2018—more than 100

days ago. At that time, Plaintiff requested materials related to the U.S. Marshals

Service Southeast Regional Task Force (“SERTF”) Standard Operating Procedures

(“SOPs”), directives, rules, or procedures. (See Exhibit C).

22. This FOIA request, submission ID 24746, requested “any and all

records concerning the U.S. Marshals Service Southeast Regional Task Force

Standard Operating Procedures, Directives, rules, or procedures.” This request also

identified fourteen specific topics relevant to Plaintiff’s inquiry.

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23. Two weeks later, on September 21, 2018, Plaintiff filed another FOIA

request seeking additional federal policies. (See Exhibit D). This request,

submission ID 27046, sought copies of US Marshal Form 122, a required form that

all employees must complete following an officer-involved shooting.

24. Since those requests were made, Plaintiff has followed-up with

repeated phone calls to the DOJ to resolve this dispute amicably. Plaintiff has been

met with resistance at each step. Several of Plaintiff’s calls have been unreturned,

and, during the few returned phone calls, the DOJ has failed to provide any

meaningful response to the status of this request.

25. The FOIA requests were narrowly-tailored and sought specific

documents highly relevant to the death of Mr. Robinson.

26. It has now been 875 days since the officers killed Mr. Robinson, and

the DOJ has yet to provide any of the documents or evidence requested and has failed

to provide any investigative reports relating to Mr. Robinson’s death.

COUNT 1 (Violation of FOIA, 5 U.S.C. § 552)

27. Plaintiff realleges paragraphs 1 through 16 as if fully stated herein.

28. Defendant is unlawfully withholding records requested by Plaintiff

pursuant to 5 U.S.C. § 552.

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29. Plaintiff and the people of Fulton County, Georgia are irreparably

harmed by Defendant’s unlawful withholding of records responsive to Plaintiff’s

FOIA request, because, without the requested information, Plaintiff is unable to

fulfill its duty to the community to enforce the laws of Georgia against these officers,

and Plaintiff and the people of Fulton County will continue to be irreparably harmed

unless Defendant is compelled to conform its conduct to the requirements of the law.

WHEREFORE, Plaintiff Office of the Fulton County District Attorney

respectfully requests that the Court: (1) order Defendant Department of Justice to

conduct searches for any and all responsive records to Plaintiff’s FOIA requests and

demonstrate that it employed search methods reasonably likely to lead to the

discovery of records responsive to Plaintiff’s FOIA request; (2) order Defendant to

produce, by a date certain, any and all non-exempt records to Plaintiff’s FOIA

request and a Vaughn index of any responsive records withheld under claim of

exemption; (3) enjoin Defendant from continuing to withhold any and all non-

exempt records responsive to Plaintiff’s FOIA request; (4) grant Plaintiff an award

of attorneys’ fees and other litigation costs reasonably incurred in this action

pursuant to 5 U.S.C. § 552(a)(4)(E); and (5) grant Plaintiff such other relief as the

Court deems just and proper.

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Dated: December 27, 2018 Respectfully submitted,

/s/ Lyndsey Rudder

Lyndsey Rudder
Georgia Bar No. 421055
Deputy District Attorney
Office of the Fulton County District
Attorney
136 Pryor Street, SW, Third Floor
Atlanta, Georgia 30303
Phone: 404.612.4972
Fax: 404.332.0397
lyndsey.rudder@fultoncountyga.gov

/s/ A. Lee Bentley, III

A. Lee Bentley, III
Florida Bar No. 1002269
Bradley Arant Boult Cummings LLP
100 N. Tampa Street, Suite 2200
Tampa, Florida 33602
Phone: 813.559.5500
lbentley@bradley.com
Pro hac vice (application to be filed)

/s/ Jason Paul Mehta

Jason Paul Mehta
Florida Bar No. 106110
Bradley Arant Boult Cummings LLP
100 N. Tampa Street, Suite 2200
Tampa, Florida 33602
Phone: 813.559.5500
jmehta@bradley.com
Pro hac vice (application to be filed)

Counsel for Plaintiff

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CERTIFICATE OF COMPLIANCE WITH LR 5.1

I hereby certify that the foregoing document is written in 14 point Times New

Roman font in accordance with Local Rule 5.1.

/s/ Lyndsey Rudder

Lyndsey Rudder

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4812-3894-2340.1
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 Case
JS44 (Rev. 6/2017 NDGA) 1:18-mi-99999-UNA CIVIL
Document 4142-5
COVER SHEETFiled 12/27/18 Page 1 of 2
The JS44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as provided by
local rules of court. This form is required for the use of the Clerk of Court for the purpose of initiating the civil docket record. (SEE INSTRUCTIONS ATTACHED)

I. (a) PLAINTIFF(S) DEFENDANT(S)

OFFICE OF THE FULTON COUNTY DISTRICT ATTORNEY DEPARTMENT OF JUSTICE, an agency of the United
States

(b) COUNTY OF RESIDENCE OF FIRST LISTED COUNTY OF RESIDENCE OF FIRST LISTED

PLAINTIFF Fulton DEFENDANT Fulton
(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)

NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND
INVOLVED

(c) ATTORNEYS (FIRM NAME, ADDRESS, TELEPHONE NUMBER, AND ATTORNEYS (IF KNOWN)
E-MAIL ADDRESS)

Lyndsey Rudder, Deputy District Attorney

Office of the Fulton County District Attorney
136 Pryor Street, SW, Third Floor
Atlanta, Georgia 30303 -- Phone: 404.612.4972
Email: lyndsey.rudder@fultoncountyga.gov

II. BASIS OF JURISDICTION III. CITIZENSHIP OF PRINCIPAL PARTIES

(PLACE AN “X” IN ONE BOX ONLY) (PLACE AN “X” IN ONE BOX FOR PLAINTIFF AND ONE BOX FOR DEFENDANT)
(FOR DIVERSITY CASES ONLY)

PLF DEF PLF DEF

1 U.S. GOVERNMENT 3 FEDERAL QUESTION 1 1 CITIZEN OF THIS STATE 4 4 INCORPORATED OR PRINCIPAL

PLAINTIFF (U.S. GOVERNMENT NOT A PARTY) PLACE OF BUSINESS IN THIS STATE

2 U.S. GOVERNMENT 4 DIVERSITY 2 2 CITIZEN OF ANOTHER STATE 5 5 INCORPORATED AND PRINCIPAL

DEFENDANT (INDICATE CITIZENSHIP OF PARTIES PLACE OF BUSINESS IN ANOTHER STATE
IN ITEM III)
3 3 CITIZEN OR SUBJECT OF A 6 6 FOREIGN NATION
FOREIGN COUNTRY

IV. ORIGIN (PLACE AN “X “IN ONE BOX ONLY)

TRANSFERRED FROM MULTIDISTRICT APPEAL TO DISTRICT JUDGE
1 ORIGINAL 2 REMOVED FROM 3 REMANDED FROM 4 REINSTATED OR 5 ANOTHER DISTRICT 6 LITIGATION - 7 FROM MAGISTRATE JUDGE
PROCEEDING STATE COURT APPELLATE COURT REOPENED (Specify District) TRANSFER JUDGMENT

MULTIDISTRICT
8 LITIGATION -
DIRECT FILE

V. CAUSE OF ACTIONJURISDICTIONAL
(CITE THE U.S. CIVIL STATUTE UNDER WHICH YOU ARE FILING AND WRITE A BRIEF STATEMENT OF CAUSE - DO NOT CITE
STATUTES UNLESS DIVERSITY)

5 U.S.C. Section 552 - unlawful withholding of records request under the Freedom of Information Act

(IF COMPLEX, CHECK REASON BELOW)

1. Unusually large number of parties. 6. Problems locating or preserving evidence

2. Unusually large number of claims or defenses. 7. Pending parallel investigations or actions by government.
3. Factual issues are exceptionally complex 8. Multiple use of experts.
4. Greater than normal volume of evidence. 9. Need for discovery outside United States boundaries.
5. Extended discovery period is needed. 10. Existence of highly technical issues and proof.

CONTINUED ON REVERSE
FOR OFFICE USE ONLY

RECEIPT # AMOUNT $ APPLYING IFP MAG. JUDGE (IFP) ______________________

JUDGE MAG. JUDGE NATURE OF SUIT CAUSE OF ACTION______________________

(Referral)
 Case 1:18-mi-99999-UNA Document 4142-5 Filed 12/27/18 Page 2 of 2
VI. NATURE OF SUIT (PLACE AN “X” IN ONE BOX ONLY)
CONTRACT - "0" MONTHS DISCOVERY TRACK
150 RECOVERY OF OVERPAYMENT &
ENFORCEMENT OF JUDGMENT
152 RECOVERY OF DEFAULTED STUDENT
LOANS (Excl. Veterans)
153 RECOVERY OF OVERPAYMENT OF
VETERAN'S BENEFITS
CONTRACT - "4" MONTHS DISCOVERY TRACK
110 INSURANCE
120 MARINE
130 MILLER ACT
140 NEGOTIABLE INSTRUMENT
151 MEDICARE ACT
160 STOCKHOLDERS' SUITS
190 OTHER CONTRACT
195 CONTRACT PRODUCT LIABILITY
196 FRANCHISE
REAL PROPERTY - "4" MONTHS DISCOVERY
TRACK
210 LAND CONDEMNATION
220 FORECLOSURE
230 RENT LEASE & EJECTMENT
240 TORTS TO LAND
245 TORT PRODUCT LIABILITY
290 ALL OTHER REAL PROPERTY
TORTS - PERSONAL INJURY - "4" MONTHS
DISCOVERY TRACK
310 AIRPLANE
315 AIRPLANE PRODUCT LIABILITY
320 ASSAULT, LIBEL & SLANDER
330 FEDERAL EMPLOYERS' LIABILITY
340 MARINE
345 MARINE PRODUCT LIABILITY
350 MOTOR VEHICLE
355 MOTOR VEHICLE PRODUCT LIABILITY
360 OTHER PERSONAL INJURY
362 PERSONAL INJURY - MEDICAL
MALPRACTICE
365 PERSONAL INJURY - PRODUCT LIABILITY
367 PERSONAL INJURY - HEALTH CARE/
PHARMACEUTICAL PRODUCT LIABILITY
368 ASBESTOS PERSONAL INJURY PRODUCT
LIABILITY
CIVIL RIGHTS - "4" MONTHS DISCOVERY TRACK SOCIAL SECURITY - "0" MONTHS DISCOVERY
440 OTHER CIVIL RIGHTS TRACK
441 VOTING 861 HIA (1395ff)
442 EMPLOYMENT 862 BLACK LUNG (923)
443 HOUSING/ ACCOMMODATIONS 863 DIWC (405(g))
445 AMERICANS with DISABILITIES - Employment 863 DIWW (405(g))
446 AMERICANS with DISABILITIES - Other 864 SSID TITLE XVI
448 EDUCATION 865 RSI (405(g))
FEDERAL TAX SUITS - "4" MONTHS DISCOVERY
IMMIGRATION - "0" MONTHS DISCOVERY TRACK TRACK
462 NATURALIZATION APPLICATION 870 TAXES (U.S. Plaintiff or Defendant)
465 OTHER IMMIGRATION ACTIONS 871 IRS - THIRD PARTY 26 USC 7609
PRISONER PETITIONS - "0" MONTHS DISCOVERY OTHER STATUTES - "4" MONTHS DISCOVERY
TRACK TRACK
463 HABEAS CORPUS- Alien Detainee 375 FALSE CLAIMS ACT
510 MOTIONS TO VACATE SENTENCE 376 Qui Tam 31 USC 3729(a)
530 HABEAS CORPUS 400 STATE REAPPORTIONMENT
535 HABEAS CORPUS DEATH PENALTY 430 BANKS AND BANKING
540 MANDAMUS & OTHER 450 COMMERCE/ICC RATES/ETC.
550 CIVIL RIGHTS - Filed Pro se 460 DEPORTATION
555 PRISON CONDITION(S) - Filed Pro se 470 RACKETEER INFLUENCED AND CORRUPT
560 CIVIL DETAINEE: CONDITIONS OF ORGANIZATIONS
CONFINEMENT 480 CONSUMER CREDIT
490 CABLE/SATELLITE TV
PRISONER PETITIONS - "4" MONTHS DISCOVERY 890 OTHER STATUTORY ACTIONS
TRACK 891 AGRICULTURAL ACTS
550 CIVIL RIGHTS - Filed by Counsel 893 ENVIRONMENTAL MATTERS
555 PRISON CONDITION(S) - Filed by Counsel 895 FREEDOM OF INFORMATION ACT
899 ADMINISTRATIVE PROCEDURES ACT /
FORFEITURE/PENALTY - "4" MONTHS DISCOVERY REVIEW OR APPEAL OF AGENCY DECISION
TRACK 950 CONSTITUTIONALITY OF STATE STATUTES
625 DRUG RELATED SEIZURE OF PROPERTY
21 USC 881 OTHER STATUTES - "8" MONTHS DISCOVERY
690 OTHER TRACK
410 ANTITRUST
LABOR - "4" MONTHS DISCOVERY TRACK 850 SECURITIES / COMMODITIES / EXCHANGE
710 FAIR LABOR STANDARDS ACT
720 LABOR/MGMT. RELATIONS OTHER STATUTES - “0" MONTHS DISCOVERY
740 RAILWAY LABOR ACT TRACK
751 FAMILY and MEDICAL LEAVE ACT 896 ARBITRATION
790 OTHER LABOR LITIGATION (Confirm / Vacate / Order / Modify)
791 EMPL. RET. INC. SECURITY ACT
PROPERTY RIGHTS - "4" MONTHS DISCOVERY

TORTS - PERSONAL PROPERTY - "4" MONTHS

TRACK
820 COPYRIGHTS
* PLEASE NOTE DISCOVERY
DISCOVERY TRACK 840 TRADEMARK TRACK FOR EACH CASE TYPE.
370 OTHER FRAUD SEE LOCAL RULE 26.3
371 TRUTH IN LENDING PROPERTY RIGHTS - "8" MONTHS DISCOVERY
380 OTHER PERSONAL PROPERTY DAMAGE TRACK
385 PROPERTY DAMAGE PRODUCT LIABILITY 830 PATENT
835 PATENT-ABBREVIATED NEW DRUG
BANKRUPTCY - "0" MONTHS DISCOVERY TRACK APPLICATIONS (ANDA) - a/k/a
422 APPEAL 28 USC 158 Hatch-Waxman cases
423 WITHDRAWAL 28 USC 157

VII. REQUESTED IN COMPLAINT:

CHECK IF CLASS ACTION UNDER F.R.Civ.P. 23 DEMAND $_____________________________
JURY DEMAND YES NO (CHECK YES ONLY IF DEMANDED IN COMPLAINT)

VIII. RELATED/REFILED CASE(S) IF ANY

JUDGE_______________________________ DOCKET NO._______________________
CIVIL CASES ARE DEEMED RELATED IF THE PENDING CASE INVOLVES: (CHECK APPROPRIATE BOX)
1. PROPERTY INCLUDED IN AN EARLIER NUMBERED PENDING SUIT.
2. SAME ISSUE OF FACT OR ARISES OUT OF THE SAME EVENT OR TRANSACTION INCLUDED IN AN EARLIER NUMBERED PENDING SUIT.
3. VALIDITY OR INFRINGEMENT OF THE SAME PATENT, COPYRIGHT OR TRADEMARK INCLUDED IN AN EARLIER NUMBERED PENDING SUIT.
4. APPEALS ARISING OUT OF THE SAME BANKRUPTCY CASE AND ANY CASE RELATED THERETO WHICH HAVE BEEN DECIDED BY THE SAME
BANKRUPTCY JUDGE.
5. REPETITIVE CASES FILED BY PRO SE LITIGANTS.
6. COMPANION OR RELATED CASE TO CASE(S) BEING SIMULTANEOUSLY FILED (INCLUDE ABBREVIATED STYLE OF OTHER CASE(S)):

7. EITHER SAME OR ALL OF THE PARTIES AND ISSUES IN THIS CASE WERE PREVIOUSLY INVOLVED IN CASE NO. , WHICH WAS
DISMISSED. This case IS IS NOT (check one box) SUBSTANTIALLY THE SAME CASE.

SIGNATURE OF ATTORNEY OF RECORD DATE

 Case 1:18-mi-99999-UNA Document 4142-6 Filed 12/27/18 Page 1 of 2

AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the
Northern District
__________ District of
of Georgia
__________

OFFICE OF THE FULTON COUNTY DISTRICT )

ATTORNEY )
)
)
Plaintiff(s) )
)
v. Civil Action No.
)
DEPARTMENT OF JUSTICE, an agency of the )
United States )
)
)
Defendant(s) )

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address) United States Attorney's Office for the Northern District of Georgia
Attn: Civil Process Clerk
Richard B. Russell Federal Building
75 Ted Turner Drive SW, Suite 600
Atlanta, Georgia 30303-3309

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you
are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.
P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of
the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,
whose name and address are: Lyndsey Rudder
Deputy District Attorney
Office of the Fulton County District Attorney
136 Pryor Street, SW, Third Floor
Atlanta, Georgia 30303

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.
You also must file your answer or motion with the court.

CLERK OF COURT

Date:
Signature of Clerk or Deputy Clerk
 Case 1:18-mi-99999-UNA Document 4142-6 Filed 12/27/18 Page 2 of 2

AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

’ I personally served the summons on the individual at (place)

on (date) ; or

’ I left the summons at the individual’s residence or usual place of abode with (name)
, a person of suitable age and discretion who resides there,
on (date) , and mailed a copy to the individual’s last known address; or

’ I served the summons on (name of individual) , who is

designated by law to accept service of process on behalf of (name of organization)
on (date) ; or

’ I returned the summons unexecuted because ; or

’ Other (specify):
.

My fees are $ for travel and $ for services, for a total of $ 0.00 .

I declare under penalty of perjury that this information is true.

Date:
Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

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