CA 1-A [Rev. June 2017] Super. Ct. Civ. R. 4
Washington, 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 ACKNOWLEDGMENT 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 you are authorized to
receive 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 return this form, you (or the party on whose behalf you are being served) must answer
the complaint within 21 days after you have signed, dated, and returned the form (or within 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 Acknowledgment of Receipt of Summons, Complaint, Initial Order, and Any Addendum was
mailed on (insert date): __________________.
________________________________
Signature
________________________________
Date of Signature
ACKNOWLEDGMENT OF RECEIPT OF SUMMONS,
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
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