Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 1 of 7 UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF FLORIDA FORT LAUDERDALE DIVISION Case. No. _____________________ ) ) ) ) ) ) ) ) Plaintiffs, ) ) v. ) ) ALL NATION STAFFING, LLC, ) NESTOR B. MOLINA, and ) PATRICK DAMIAN BURNS, ) ) Defendants. ) ___________________________________ ) MARVIN A. BUEZO CABALLERO, RENSO R. CASTILLO CLANCO, ALEJANDRO CRUZ PONCE, DIONICIO MARCIA CHAVER, SELSO PALMA ULLOA, and ANTHONY A. SIERRA HERNANDEZ, COMPLAINT FOR DAMAGES, COSTS OF LITIGATION AND ATTORNEY’S FEES INTRODUCTION 1. This is an action by six Honduran nationals who were recruited for agricultural jobs in Florida by Defendants All Nation Staffing, LLC, Nestor B. Molina, and Patrick Damian Burns. 2. Plaintiffs and other workers were recruited in Honduras by Defendants and furnished to Fancy Farms, Inc. and/or G&D Farms, Inc. for employment in these companies’ respective Hillsborough County, Florida operations. 3. Plaintiffs assert claims under the Trafficking Victims Protection Reauthorization Act (hereinafter “TVPRA”), 18 U.S.C. §§ 1589 and 1590. Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 2 of 7 JURISDICTION 4. Jurisdiction is conferred on this Court by 18 U.S.C. § 1595(a), this action arising under the Trafficking Victims Protection Reauthorization Act. VENUE 5. Venue is proper in this District Court pursuant to 28 U.S.C. §§1391(b) and (c). PARTIES 6. Plaintiffs are citizens of Hondurans who entered the United States for employment in Hillsborough County, Florida as H2-A guest workers during the 2013-14 Florida strawberry harvest season. 7. Defendant All Nation Staffing, LLC (“ANS”) is a closely held corporation based in Davie, Florida. 8. Defendant Nestor B. Molina is the manager of ANS and a resident of Broward County, Florida. 9. Defendant, Patrick Damian Burns is the co-owner, along with Molina, of All Nation Staffing, LLC and a resident of Broward County, Florida. FACTS 10. Fancy Farms, Inc. and G & D Farms, Inc. each grow strawberries in Hillsborough County, Florida for commercial sale. These strawberries are picked by hand and require a substantial number of farmworkers during the harvest season. 11. To assist in meeting their respective manpower requirements for the 2013-2014 harvest, Fancy Farms and G&D Farms each applied for temporary labor certification to import workers from abroad. The Immigration and Nationality Act (“INA”) permits an agricultural employer who anticipates a temporary or seasonal labor shortage to import alien workers to perform - 2 -    Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 3 of 7 agricultural labor. 8 U.S.C. § 1188(a)(15)(H)(ii)(a). Aliens admitted in this fashion are often referred to as “H-2A workers.” 12. Fancy Farms, Inc. and G&D Farms, Inc. contracted with ANS to recruit and furnish H2A workers to fill the strawberry-harvesting positions described in the farms’ temporary labor certification applications. Defendants subsequently recruited and hired Plaintiffs and other individuals in Honduras to fill these positions. 13. During their recruitment of Plaintiffs as described in Paragraph 12, Defendants provided Plaintiffs with false and misleading information about the work. Among other things, Defendants promised Plaintiffs that they would each earn $900.00 per week and that they would qualify for “blue cards” or “green cards” authorizing them to live and work permanently in the United States. 14. Defendants required as a condition of hire that each Plaintiff pay a “guarantee” of between $3,000.00 and $4,000.00. Defendants stated that this sum was to ensure that the workers would not abscond from their positions with Fancy Farms, Inc. or G&D Farms. These sums were deposited by Plaintiffs into bank accounts designated by Defendants. Plaintiffs were told by Defendants that these funds would be returned to them upon completion of the harvest season. 15. The United States Department of Labor approved the temporary labor certification applications filed by Fancy Farms, Inc. and G & D Farms, Inc. Defendants arranged for appointments for Plaintiffs with the United States embassy in Tegucigalpa, Honduras. After being interviewed by the embassy staff, Plaintiffs were issued H-2A visas to work in the 2013-14 Florida strawberry harvest. Plaintiffs Marvin a. Buezo Caballero, Renso R. Castillo Clanco, Alejandro Cruz Ponce, Dionicio Marcia Chaver and Selso Palma Ulloa were issued visas for employment with Fancy Farms, Inc while Anthony A. Sierra Hernandez was issued a visa for - 3 -    Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 4 of 7 employment with G&D Farms. Plaintiffs traveled to the United States and were employed harvesting strawberries in Hillsborough County as provided for in the temporary labor certification applications filed by Fancy Farms, Inc. and G & D Farms, Inc. 16. Throughout the period Plaintiffs worked at Fancy Farms, Inc. or G&D Farms, Defendants created an atmosphere of complete control by representing to Plaintiffs that if they revealed that they had paid the “guarantee” to Defendants, the H-2A program in Honduras would be abolished, thereby eliminating the ability of Plaintiffs and other Hondurans to legally work in agricultural jobs in the United States in the future. 17. Throughout the period Plaintiffs worked at Fancy Farms, Inc. or G&D Farms, Defendants created an atmosphere of fear and complete control by threatening Plaintiffs about “consequences in Honduras,” once Defendants discovered that Plaintiffs had talked to legal services representatives about their rights in the U.S. as H-2A workers. 18. Throughout the period Plaintiffs worked at Fancy Farms, Inc. or G&D Farms, Defendants created an atmosphere of fear among Plaintiffs and their co-workers by constantly monitoring Plaintiffs and their co-workers, visiting the different labor camps in which they resided on a regular basis. 19. Plaintiffs were frightened by Defendants’ continuous threats, particularly because they were working to pay back the debts incurred in order to come to the United States and to pay the “guarantees.” Because of fear of retribution, Plaintiffs were reluctant to complain of the working conditions and the many threats by Defendants. These threats by Defendants served to foster in Plaintiffs fear and sense of helplessness. 20. Defendants also threatened to physically harm Plaintiffs upon their return to Honduras. - 4 -    Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 5 of 7 21. Despite the promises made to Plaintiffs at the time of their recruitment in Honduras, Defendants failed to return any portion of the “guarantee” funds following the conclusion of the strawberry harvest in April 2014. 22. As a result of the actions described in Paragraphs 13 through 21, Plaintiffs suffered serious emotional and financial distress and ongoing disruption to their lives. Among other things, Plaintiffs suffered from disrupted sleeping, nightmares, ongoing feelings of fear for themselves and their families in Honduras, difficulty developing trust, anxiety, depression, difficulty concentrating and stress. CLAIMS FOR RELIEF COUNT I TRAFFICKING VICTIMS PROTECTION REAUTHORIZATION ACT OF 2008 (“TVPRA”) Forced Labor, 18 U.S.C. § 1589 23. Defendants subjected Plaintiffs to forced labor by obtaining Plaintiffs’ labor and services by subjecting Plaintiffs to threats of serious harm of themselves and others, in violation of 18 U.S.C. § 1589(a). 24. Defendants knowingly provided Plaintiffs’ labor to Fancy Farms, Inc. and G&D Farms, Inc. by using a scheme, plan and pattern intended to cause Plaintiffs to believe that if they complained about the exorbitant “guarantees” to anyone, they would be forever unable to return to United States on work visas because alerting anyone of these charges would result in no H-2A visas being issued to Honduran residents in the future. Furthermore, Plaintiffs were led to believe that they would suffer serious physical and financial harm if they ever disclosed that they paid Defendants moneys to obtain their employment in the United States. Defendants thus obtained - 5 -    Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 6 of 7 the labor of Plaintiffs through abuse and threatened abuse of the law and the legal process, in violation of 18 U.S.C. §1589(a)(3). 25. Defendants have substantially benefitted financially from participating in their venture with Plaintiffs and Fancy Farms and G&D Farms. Defendants received compensation for providing workers to Fancy Farms and G&D Farms. In addition, Defendants received payments from Plaintiffs’ and other workers for the “guarantee.” Plaintiffs felt they could not leave their employment and were thus tied to it because of serious physical threats to their person. 26. As a result of the above actions by Defendants, described in this count, Plaintiffs suffered damages. 27. Plaintiffs are entitled to actual damages with respect to fees paid to Defendants as “guarantees.” 28. Plaintiffs are entitled to compensatory and punitive damages in an amount to be proven at trial and any other relief deemed appropriate, including reasonable attorney’s fees. COUNT II TRAFFICKING VICTIMS PROTECTION REAUTHORIZATION Human Trafficking, 18 U.S.C. § 1590 29. Defendants knowingly recruited, harbored and transported Plaintiffs for the purposes of subjecting them to force them to forced labor in violation of 18 U.S.C. § 1590(a). 30. Plaintiffs are entitled to compensatory and punitive damages in an amount to be proven at trial and any other relief deemed appropriate, including reasonable attorney’s fees. PRAYER FOR RELIEF WHEREFORE, Plaintiffs pray that this Court enter an order: a. Granting judgment in favor of Plaintiffs and against Defendants, on the Plaintiffs’ claims under the Trafficking Victims Protection Reauthorization Act of 2008 as set - 6 -    Case 0:14-cv-61497-KMW Document 1 Entered on FLSD Docket 06/30/2014 Page 7 of 7 out in Counts I and II and awarding each of them his compensatory and punitive damage in an amount to be determined at trial; b. Awarding Plaintiffs the costs of this action; c. Awarding Plaintiffs a reasonable attorney’s fee; and d. Granting such further relief as this Court deems just and equitable. Respectfully submitted, /s/ Karla C. Martinez Karla C. Martinez Florida Bar No. 094674 e-mail: karla@floridalegal.org /s/ Gregory S. Schell Gregory S. Schell Florida Bar No. 287199 e-mail: greg@floridalegal.org Florida Legal Services, Inc. MIGRANT FARMWORKER JUSTICE PROJECT 508 Lucerne Avenue Lake Worth, Florida 33460-3819 Telephone: (561) 582-3921 Facsimile: (561) 582-4884 Attorneys for Plaintiffs - 7 -    (Rev. 12 Entered Document 1-1 Case 0:14-cv-61497-KMW JS 44 12) on FLSD Docket 06/30/2014 Page 1 of 1 CIVIL COVER SHEET The JS 44 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, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.) NOTICE: Attorneys MUST Indicate All Re-filed Cases Below. I. (a) PLAINTIFFS Marvin A. Buezo Caballero, et al. (b) County of Residence of First Listed DEFENDANTS Plaintiff All Nations Staffing, Nestor B. Molina and Patrick Damian Burns. County of Residence of First Listed Defendant (EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY) NOTE: (c) Attorneys (Firm Name, Address, and Telephone Number) Karla C. Martinez and Gregory S. Schell 508 Lucerne Ave., Lake Worth, FL 33460; 561-582-3921 (d)Check County Where Action Arose: 13 II. BASIS OF JURISDICTION 0 I U.S. Government MIAMI- DADE (Place an MONROE "X" in One Box 43 Plaintiff 0 AO Attorneys (If Known) Not a 0 BROWARD 0 MARTIN ci ST. LUCIE PALM BEACH 0 INDIAN RIVER 0 OKEECHOBEE 0 HIGHLANDS III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an "X" in One Box for Plaintiff) (For Diversity Cases Only) and One Box for Defendant) Only) Federal Question (U.S. Government IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED. PTF Citizen of This State Party) 0 I DEF 0 PTF I Incorporated or Principal Place DEF 0 4 04 0 5 0 5 0 6 0 6 of Business In This State 0 2 U.S. Government 04 Defendant Diversity (Indicate CitLenship of Parties in Item Citizen of Another State 02 0 2 Incorporated Citizen or 0 3 0 3 Foreign III) Subject of a Foreign Country IV. NATI IR F. OF SUIT 11— CONTRACT 0 0 0 0 0 110 Insurance 120 Marine 130 Miller Act 140 Negotiable Instrument 150 Recovery of Overpayment & Enforcement ofludgment 151 Medicare Act 152 Recovery of Defaulted Student Loans 0 0 (Excl. Veterans) 0 153 Recovery of Overpayment of Veteran's Benefits 0 160 Stockholders' Suits 0 190 Other Contract 0 195 Contract Product Liability 0196 Franchise 0 240 Torts to Land 0 245 Tort Product 290 All Other Real n.a..^ PERSONAL INJURY 0310 Airplane 0315 Airplane Product Liability 0320 Assault, Libel & 0330 Slander Federal Employers' 0340 0345 Marine Product Liability Marine Liability 0350 Motor Vehicle 0355 Motor Vehicle Product Liability 0360 Other Personal Injury 0362 Personal Injury Med. Malpractice CIVIL RIGHTS 0 440 Other Civil Rights 0441 Voting 0442 Employment r-i 443 Housing/ "0 0 Liability Accommodations 445 Amer. w/Disabilities Property Employment 0446 Amer. 0448 w/Disabilities Other Education FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES PERSONAL INJURY 0 625 Drug Related Seizure 0422 Appeal 28 USC 158 0 375 False Claims Act Personal of Property 21 USC 881 0 365 Injury 0 423 Withdrawal 0 400 State Reapportionment Product Liability 0 690 Other 28 USC 157 0 410 Antitrust 0 367 Health Care0 430 Banks and Banking Pharmaceutical PROPERTY RIGHTS 0 450 Commerce Personal Injury 0 820 Copyrights 0 460 Deportation Product Liability 0 830 Patent 0 470 Racketeer Influenced and 368 Asbestos Personal 0 0840 Trademark Corrupt Organizations Product Injury 0 480 Consumer Credit LABOR SOCIAL SECURITY Liability 0 490 Cable/Sat TV PERSONAL PROPERTY 0 710 Fair Labor Standards U 861 HIA (1395(1) 0 850 Securities/Commodities/ Other Fraud 370 0 Act 0 862 Black Lung (923) Exchange 0 371 Truth in Lending 0 720 Labor/Mgmt. Relations 0863 DIWC/DIWW (405(g)) gl 890 Other Statutory Actions 0 380 Other Personal Labor 740 0 Act 0 864 SSID Title XVI Railway 0 891 Agricultural Acts 0 751 Family and Medical Property Damage 0865 RSI (405(g)) 0 893 Environmental Matters 0 385 Property Damage Leave Act 0 895 Freedom of Information Product Liability 0 790 Other Labor Litigation Act 0 791 Empl. Re. Inc. 0 896 Arbitration PRISONER PETITIONS FEDERAL TAX SUITS Security Act 0 899 Administrative Procedure Habeas Corpus: 0870 Taxes (U.S. Plaintiff Act/Review or Appeal of 0 463 Alien Detainee or Defendant) Agency Decision r—i 510 MMions to Vacate r-1871 IRS—Third Party 26 r-r 950 Constitutionality of State Sentence 7609 Statutes Other: 0 0 0 0 0 0 V. ORIGIN RI I Original Proceeding 530 General Death Penalty Mandamus & Other Civil Rights Prison Condition Civil Detainee Conditions of Confinement 535 540 550 555 560 (Place an "X" in One Box Only) 0 2 Rem oved from 0 3 Re-filed (See VI below) StateCourt VI. RELATED/ RE-FILED CASE(S) 0 4 Remstated 0 462 0 465 or Reopened a) Re-filed Case !DYES 0 IMMIGRATION Naturalization Application Other Immigration Actions 5 f5 NO Transferred from 0 6 Multidistrict another district Litigation (speciR) 7 08 Magistrate Judgment rAtepnipAigiteedcfromg b) Related Cases DYES lif NO JUDGE Cite the U.S. Civil Statute under which you are filing and Write a Brief Statement DOCKET NUMBER of Cause (Do not cite jurisdictional statutes unless diversity): absdf• ngstimunder3 thelaXPegAatUdaq, stuugyagljgs0)for forced labor of Plaintiffs. 0 CHECK IF THIS IS A CLASS ACTION DEMAND CHECK YES UNDER F.R.C.P. 23 JURY ABOVE INFORMATION IS TRUE & CORRECT TO THE BEST OF MY KNOWLEDGE DATE /7 SIGNATURE OF ATTORNEY OF RECORD 0/wM FOR OFFICE/USE WILY RECEIPT 0 Appeal to District Judge from (See instructions): VII. CAUSE OF ACTION VIII. REQUESTED IN COMPLAINT: Nation TORTS REAL PROPERTY U 210 Land Condemnation 0 220 Foreclosure 0 230 Rent Lease & Ejectment and Principal Place of Business In Another State AMOUNT IFP only if demanded in complaint: DEMAND: A -itc(4)71p= JUDGE MAG JUDGE 0 Yes i gNo Case 0:14-cv-61497-KMW AO 440 (Rev. 06 Document 1-2 Entered on FLSD Docket 06/30/2014 Page 1 of 2 12) Summons in a Civil Action UNITED STATES DISTRICT COURT for the Southern District of Florida MARVIN A. BUEZO CABALLERO, RENSO R. CASTILLO BLANCO, ALJEJANDRO CRUZ PONCE, DIONICIO MARCIA CHAVER, SELSO PALMA ULLOA, AND ANTHONY A. SIERRA HERNANDEZ Plaintiffs) Civil Action No. v. ALL NATION STAFFING, LLC, NESTOR B. MOLINA, AND PATRICK DAMIAN BURNS Defendant(s) SUMMONS IN A CIVIL ACTION To: (Defendant's name and address) All Nation Staffing, LLC do Nestor B. Molina, Registered 7790 NW 40th Street Davie, FL 33024 A lawsuit has been filed Agent against you. Within 21 days after service of this summons on or 60 days if you (not counting the day you received it) you 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: Karla C. Martinez, are Esq. (karla@floridalegal.org) Gregory S. Schell, Esq. (greg@floridalegal.org) 508 Lucerne Ave. Lake Worth, Florida 33460 Tel: (561) 582-3921 Fax: (561) 582-4884 If you fail to respond, judgment by default will be entered You also must file your answer or motion with the court. against you for the relief demanded in the complaint. CLERK OF COURT Date: Signature of Clerk or Deputy Clerk AO 440 (Rev. 06.12) Summons in a Entered Document 1-2 Case 0:14-cv-61497-KMW Civil Action on FLSD Docket 06/30/2014 Page 2 of 2 (Page 2) Civil Action No. PROOF OF SERVICE (This section should not be filed with the court unless This was summons received CI I R. Civ. P. 4 (1)) for (name of individual and title, if any) by me on (date) personally served the summons on the individual at (place) on CI I left the summons at the individual's residence a on required by Fed. (date), and mailed CI I served the summons on designated by law to a or usual place of abode with (name) copy to the individual's last known address; there, or (name of individual), who is accept service of process summons or person of suitable age and discretion who resides on behalf of (name of organization) on I returned the (date); unexecuted (date); or because; or Other (specify): My fees are I declare under for travel and penalty of perjury that this information is for services, for a total of true. Date: Server's signature Printed name and title Server's address Additional information regarding attempted service, etc: 0.00 Case 0:14-cv-61497-KMW AO 440 (Rev. 06 12) Summons in a Document 1-3 Entered on FLSD Docket 06/30/2014 Page 1 of 2 Civil Action UNITED STATES DISTRICT COURT for the Southern District of Florida MARVIN A. BUEZO CABALLERO, RENSO R. CASTILLO BLANCO, ALJEJANDRO CRUZ PONCE, DIONICIO MARCIA CHAVER, SELSO PALMA ULLOA, AND ANTHONY A. SIERRA HERNANDEZ Plaintiff(s) Civil Action No. v. ALL NATION STAFFING, LLC, NESTOR B. MOLINA, AND PATRICK DAMIAN BURNS Defendant(s) SUMMONS IN A CIVIL ACTION To: (Defendant's name and address) Nestor B. Molina 7790 NW 40th Street Davie, FL 33024 A lawsuit has been filed against you. Within 21 days after service of this summons on you (not counting the day or 60 days if you received it) you 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: Karla C. Martinez, Esq. (karla@floridalegal.org) are S. Schell, Esq. (greg@floridalegal.org) 508 Lucerne Ave. Lake Worth, Florida 33460 Tel: (561) 582-3921 Fax: (561) 582-4884 Gregory If you fail to respond, judgment by default will be entered You also must file your answer or motion with the court. against you for the relief demanded in the complaint. CLERK OF COURT Date: Signature of Clerk or Deputy Clerk Case 0:14-cv-61497-KMW AO 440 (Rev. 06:12) Summons in a Entered Document 1-3 Civil Action on FLSD Docket 06/30/2014 Page 2 of 2 (Page 2) Civil Action No. PROOF OF SERVICE (This section should not be filed with the court unless This was summons received O I R. Civ. P. 4 (I)) for (name of individual and title, ifany) by me on (date) personally served the summons on the individual at (place) on CI I left the summons at the individual's residence a on required by Fed. (date), and mailed El I served the designated by summons on a or usual place person of suitable age and discretion who resides address; there, or (name of individual), who is on behalf of (name of organization) on summons or of abode with (name) copy to the individual's last known law to accept service of process O I returned the (date); unexecuted (date); or because; or O Other (specib): My fees are I declare under for travel and penalty of perjury that this information is for services, for a total of true. Date: Server's signature Printed name and title Server's address Additional information regarding attempted service, etc: 0.00 Case 0:14-cv-61497-KMW AO 440 (Rev. 06.12) Summons in a Document 1-4 Entered on FLSD Docket 06/30/2014 Page 1 of 2 Civil Action UNITED STATES DISTRICT COURT for the Southern District of Florida MARVIN A. BUEZO CABALLERO, RENSO R. CASTILLO BLANCO, ALJEJANDRO CRUZ PONCE, DIONICIO MARCIA CHAVER, SELSO PALMA ULLOA, AND ANTHONY A. SIERRA HERNANDEZ Plain tiff(s) v.; Civil Action No. ALL NATION STAFFING, LLC, NESTOR B MOLINA, AND PATRICK DAMIAN BURNS Defendant(s) SUMMONS IN A CIVIL ACTION To: (Defendant 's name and address) Patrick Damian Burns 7780 NW 40th Street Davie, FL 33024 A lawsuit has been filed against you. Within 21 days after service of this summons on you (not or 60 days if counting the day you received it) you the United States or a United States agency, or an officer or of the United States described in Fed. R. Civ. employee 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: Karla C. Martinez, Esq. are (karla@floridalegal.org) Gregory S. Schell, Esq. (greg@floridalegal.org) 508 Lucerne Ave. Lake Worth, Florida 33460 Tel: (561) 582-3921 Fax: (561) 582-4884 If you fail to respond, judgment by default will be entered You also must file your answer or motion with the court. against you for the relief demanded in the complaint. CLERK OF COURT Date: Signature of Clerk or Deputy Clerk Case 0:14-cv-61497-KMW AO 440 (Rev. Entered Document 1-4 FLSD Docket 06/30/2014 on Page 2 of 2 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 This was summons received El I R. Civ. P. 4 (I)) for (name of individual and title, if any) by me on (date) personally served the summons on the individual at (place) on O I left the summons at the individual's residence a on required by Fed. (date), and mailed O I served the designated by summons on a or usual place person of suitable age and discretion who resides address; there, or (name of individual), who is on behalf of (name of organization) on summons or of abode with (name) copy to the individual's last known law to accept service of process CI I returned the Nato; unexecuted (date); or because; or O Other (specify): My fees are I declare under for travel and penalty of perjury that this information for services, for a total of is true. Date: Server's signature Printed name and title Server's address Additional information regarding attempted service, etc: 0.00