Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 1 of 8 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND Northern Division JARED T. BREEN 3806 Apple Way Marietta, Georgia 30066 Plaintiff * * * v. * 7TH INNING STRETCH, LP 6400 Hobbs Road Salisbury, Maryland 21804 * Serve on: Chris Bitters, Resident Agent 6400 Hobbs Road Salisbury, Maryland 21804 and WICOMICO COUNTY, MARYLAND Serve on: R. Wayne Strausburg Government Office Building 125 North Division Street Salisbury, Maryland 21801 * * Civil Action No. * * * * * * * * * Defendants * * * * * * * * * COMPLAINT AND DEMAND FOR JURY TRIAL * * COMES NOW the Plaintiff, Jared T. Breen, by his undersigned attorneys, pursuant to 28 U.S.C. § 1332 and the Federal Rules of Civil Procedure, to bring suit against the Defendants, 7th Inning Stretch, LP and Wicomico County, Maryland, and further states as follows: Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 2 of 8 PARTIES 1. Plaintiff, Jared T. Breen (“Breen”) is a citizen and resident of Cobb County, Georgia who maintains his domicile at 3806 Apple Way, Marietta, Georgia, 30066.. 2. Defendant, 7th Inning Stretch, LP (“7th Inning Stretch”) is a Maryland limited partnership with its principal office located at 6400 Hobbs Road, Salisbury, Maryland 21804. 3. Defendant, Wicomico County, Maryland (“Wicomico County”) is a municipality and local government in the State of Maryland. JURISDICTION AND VENUE 4. This Court has jurisdiction over the parties and subject matter of this action pursuant to 28 U.S.C. § 1332 in that there is diversity of citizenship and the amount in controversy exceeds $75,000.00. 5. This Court is the proper venue for this action pursuant to 28 U.S.C. § 1391. FACTS COMMON TO ALL COUNTS 6. In 2013, Breen achieved his life-long dream of playing professional baseball when he was drafted by the Major League Baseball team, the Baltimore Orioles Limited Partnership (the “Orioles”). 7. The Orioles directed Breen to play for their Minor League Baseball affiliate, the Delmarva Shorebirds (“Shorebirds”) in 2014 and 2015. Defendant, 7th Inning Stretch owns the Shorebirds. 8. The Shorebirds play their home games in the Arthur W. Perdue Stadium (the “Stadium”) outside Salisbury, Maryland. Wicomico County owns the Stadium. 2 Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 3 of 8 9. Wicomico County planned, designed, developed and oversaw construction of the Stadium, which opened in 2006. 10. Upon information and belief, 7th Inning Stretch operates and/or leases the Stadium pursuant to an agreement with Wicomico County. 11. Inside the Stadium, running parallel to the third-base foul line, the Defendants designed, constructed, and/or maintained a 6-foot high concrete wall to separate the playing field from a spectator seating area (the “Wall”). 12. At all relevant times, contrary to applicable safety standards and practices, the Wall was left unpadded so that its vertical concrete face was exposed to the baseball field of play. 13. On July 3, 2015, the Shorebirds hosted a baseball game at the Stadium (the “Game”). The Game was heavily attended. Those present included Breen’s girlfriend, her mother, and her step-father. 14. During the first inning of the Game, Breen played at the shortstop position. The opposing team’s batter hit a pitch, causing the baseball to arc high into the air towards the third-base outfield. Breen was in the vicinity of the baseball and had only seconds to run and try to catch it. 15. Breen tracked the baseball by looking over his shoulder toward home plate while planning to catch the ball, which was heading toward the third-base outfield. While keeping his gaze focused on the ball and running under its arc, Breen violently collided with the unprotected and unpadded Wall (the “Accident”). 3 Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 4 of 8 16. Breen’s right foot, right knee, and head first struck the Wall, followed by his entire body. He immediately fell to the ground and could not get up or move his legs. He suffered incredible pain and discomfort after the Accident. 17. Medical personnel attended to Breen where he fell, within the sight of the spectators. His injuries were so severe that attending medical personnel cut away his uniform and bound him in the fetal position to immobilize his spine. An ambulance was brought onto the field to transport Breen to Peninsula Regional Medical Center in Salisbury, Maryland. 18. As a result of the Accident, Breen suffered numerous serious injuries, including a fractured right patella, a broken orbital, a concussion, a fractured nose, a punctured sinus, and trauma to his back. 19. Despite months of treatment and rehabilitation since the Accident, Breen has not recovered entirely from his injuries, leaving him permanently partially disabled. The Accident ended his dream of playing professional baseball. COUNT I (Negligence as to Wicomico County) 20. The provisions of Paragraphs 1 through 19 are incorporated by reference as if fully set forth herein. 21. The height, material, location, construction, design, and maintenance of the Wall created a defective and dangerous condition for baseball players at the Stadium. 22. Defendant, Wicomico County was aware of the pre-existing defective and dangerous condition presented by the Wall prior to entering into an agreement with 7th Inning 4 Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 5 of 8 Stretch for the operation of the Stadium. As the Stadium owner, Wicomico County owed Breen a non-delegable duty of care to provide and maintain the safety of the premises. 23. Wicomico County breached its duty of care to Breen by failing to remedy or adequately warn of the dangerous condition presented by the Wall including, without limitation, implementing basic industry-wide safeguards such as attaching protective pads to the Wall. Indeed, following this Accident, such padding was installed on the Wall. 24. The breach of this duty of care by Wicomico County proximately caused serious, painful, and permanent injuries to Breen. All of the injuries sustained by Breen were caused solely by the negligence of Wicomico County, without any contributory negligence on the part of Breen. WHEREFORE, Plaintiff, Jared T. Breen demands judgment against Defendant Wicomico County, Maryland, for an amount exceeding $75,000 in compensatory damages, plus interest, costs, and such other and further relief as this Court deems necessary and proper. COUNT II (Negligence as to 7th Inning Stretch) 25. The provisions of Paragraphs 1 through 24 are incorporated by reference as if fully set forth herein. 26. The aforesaid dangerous, defective and hazardous condition presented by the Wall was fully known to the Defendant, 7th Inning Stretch, at the time it entered into an agreement with Wicomico County to lease and/or operate the Stadium. 7th Inning Stretch also was fully aware of this hazard on July 3, 2015. 5 Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 6 of 8 27. As the operator/leasee of the Stadium, Defendant, 7th Inning Stretch was responsible for the maintenance and control of the premises. As such, 7th Inning Stretch owed a duty of care to Breen to exercise reasonable care in maintaining the Stadium in a safe condition, suitable for minor league professional baseball games. 28. Defendant, 7th Inning Stretch breached its duty of care owed to Breen by failing to both maintain the Wall in a safe condition or adequately warn of the dangerous condition of the Wall, including, without limitation, implementing basic safeguards such as attaching protective pads to the Wall. Indeed, following this Accident, such padding was later installed on the Wall. 29. The breach of the duty of care owed to Breen by 7th Inning Stretch proximately caused him to suffer serious, painful, and permanent injuries. All such injuries were caused solely by the negligence of 7th Inning Stretch, without any contributory negligence by Breen. WHEREFORE, Plaintiff Jared T. Breen demands judgment against 7th Inning Stretch, LP for an amount exceeding $75,000 in compensatory damages, plus interest, costs, and such other and further relief as this Court deems necessary and proper. COUNT III (Negligent Design and Construction as to Wicomico County) 30. The provisions of Paragraphs 1 through 29 are incorporated by reference as if fully set forth herein. 31. As the developer of the Stadium, Wicomico County owed foreseeable invitees such as Breen a duty to ensure that the Stadium was designed and constructed free of unreasonably dangerous conditions. 6 Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 7 of 8 32. Wicomico County breached its duty to Breen by overseeing and approving the design and construction of the Wall, including, without limitation, the height, the material used, the location, and the failure to incorporate standard protective elements such as adequate padding on an area where a baseball player’s potential impact with the Wall was reasonably foreseeable. 33. The breach of this duty of care by Wicomico County proximately caused serious, painful, and permanent injuries to Breen. All of the injuries sustained by Breen were caused solely by the negligence of Wicomico County, without any contributory negligence on the part of Breen. WHEREFORE, Plaintiff Jared T. Breen demands judgment against Defendant Wicomico County, Maryland for an amount exceeding $75,000 in compensatory damages, plus interest, costs, and such other and further relief as this Court deems necessary and proper. /s/ Russell J. Pope Russell J. Pope Bar No. 03645 TREANOR, POPE & HUGHES, P.A. 500 York Road Towson, Maryland 21204 Tel: (410) 494-7777 Fax: (410) 494-1658 rjpope@tph-law.com Attorneys for Plaintiff, Jared T. Breen 7 Case 1:18-cv-01943-DKC Document 1 Filed 06/27/18 Page 8 of 8 DEMAND FOR JURY TRIAL The Plaintiff, Jared T. Breen, pursuant to Rule 38 of the Federal Rules of Civil Procedure, hereby demands a trial by jury on all issues so triable in this action. /s/ Russell J. Pope Russell J. Pope Bar No. 03645 TREANOR, POPE & HUGHES, P.A. 500 York Road Towson, Maryland 21204 Tel: (410) 494-7777 Fax: (410) 494-1658 rjpope@tph-law.com Attorneys for Plaintiff, Jared T. Breen 8 Case Document 1-1 Filed 06/27/18 Page 1 of 2 .l544 (Rev. n7/ 6) CIVIL COVER SHEET The 44 civil cover sheet and the information contained hereinneithcr replace nor suppiet?nent the ?lvin and service of pleadings or other papers as re uired by law, except as provided by local rules of?eourt? This term, approved by the Jud1c1al Conference ot?the mted States in eptember 19M, :3 required for the use ot?the lerk of Court for the purpose of Initiating the cunt docket sheet. (1?;le ON Faith/i.) I. PLAINTIFFS DEFENDANTS JARED T. BREEN 7th inning Stretch, LP, et al. 3806 Apple Way 6400 Hobbs Road Marietta, Georgia 30066 Salisbury, Maryland 21804 County of Residence of First Listed Plaintiff County ofltesidence of First Listed Defendant . (errant av its. PLAINTIFF (IN U.S. PLAINTIFF rinses om. 10 NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED. (C) Attorneys {Firm Norrie. Address. and telephone Number) Attorneys (IfKnown) Russell J. Pope. Esq., Treanor Pope 8; Hughes, PA. 500 York Road, Towson, Maryland 21204 (410) 494-7777 I II. BASIS OF JURISDICTION (Place an ?X?r?nOne But? Only) 111. CITIZENSHIP OF PRINCIPAL PARTIES (Place on in One (Ivor Diver-star {Taxes Duty) and One Bat-for Defendant} US. Government 3 Federal Question PTF DEF PTF DEF Plaintiff (US. Government Not a Party) Citizen of This State 1 l3 1 Incorporated or Principal Place El 4 Fl 4 of Business In This State 2 .8. Government P5: 4 Diversity itizcn of Another State 2 CI 2 incorporated and Principal Place 5 El 5 Defendant (Indicate (Jt?or?cs in Item of Business In Another State Citizen or Subject of a CI 3 3 Foreign Nation El 6 6 Foreign Country IV. NATURE OF SUIT {Place an In One Box Un?t) . name-r. mars . . v. t. . .. assassins ., orange-rantings 1 IO Insurance PERSONAL INJURY PERSONAL INJURY CI 625 Drug Related Seizure CI ?122 Appeal 28 USC ?58 CI 375 False Claims Act Cl ?20 Marine CI 3ft) Airplane CI 365 Personal injury - of Property 2] USC SEI El 423 Withdrawal 376 Qui Tam {3t USC [30 Milier Act Cl 315 Airplane Product Product Liability El 690 Other 28 USC 157 3729(a)) CI 140 Negotiable Instrument Liability 367 Health Carerf JII 408 State Reapportionment CI 150 Recovely of Overpayment CI 320 Assault, Libel Pharmaceutical .3 CI 410 Antitrust Enforcement of Judgment Slander Personal Injury 820 Copyrights 430 Banks and Banking ISI Medicare Act Cl 330 Federal Employers? Product Liability CI 830 Patent El 450 Commerce t52 Recovery of Defaulted Liability CI 368 Asbestos Personal 840 Trademark El 460 Deportation Student Loans 346 Marine Injury Product El 470 Racketeer In?uenced and (Excludes Veterans) Cl 35 Marine Product Liability . OR .. Corrupt Organizations CI 153 Recovery of Overpayment Liability PERSONAL PROPERTY El 710 an Labor Standards 861 (1395f?) El 480 Consumer Credit of Veteran?s Bene?ts El 350 Motor Vehicle l3 370 Other Fraud Act El 862 Black Lung (923) El 490 Cable/Sat TV CI 160 Slocltholders? Suits CI 355 Motor Vehicle Truth in Lending Cl 720 Labor/Management El 863 {40565)} El 850 Cl l90 Other Contract Product Liability 380 Other Personal Relations CI 864 SSID Title XVI Exchange I3 ?95 Contract Product Liability l3 360 Other Personal Property Damage El 740 Railway Labor Act CI 865 RSI (405(gll 890 Other Statutory Actions El I96 Franchise Injury El 385 Property Damage El 75] Family and Medical 89] Agricultural Acts Cl 362 Personal injury - Product Liability Leave Act El 893 Environmental Matters . Medical Malpt?ztiee 790 Other Labor Litigation El 895 Freedom of Information . .. . .. . is? 79! Employee Retirement Act CI 210 Land Condemnation CI 440 Other Civil Rights Habeas Corpus: Income Security Act 870 Taxes (US. Plainti?i' CI 896 Arbitration Cl 220 Foreclosure 44] Voting 463 Alien Detainee or Defendant) 89?) Administrative Procedure [3 230 Rent Lease El 442 Employment El 510 Motions to Vacate El 87! IRS?Third Party Act/Review or Appeal of 240 Torts to Land 443 Housing! Sentence 26 USC 7609 Agency Decision 245 Tort Product Liability Accommodations El 530 General CI 950 onstitutionalit)r of 290 All Other Real Property El 445 Amer. w/Disabilities - 535 Death Penalty State Statutes Employment Other: 462 Naturalization Application CI 446 Amer. \leisabilities CI 540 Mandamus Other CI 465 Other Immigration Other CI 550 Civil Rights Actions CI 448 Education 555 Prison Condition I3 560 Civil Detainee - Conditions of Con?nement V. ORIGIN (Place an in One Box Duty) 1 Original El 2 Removed from El 3 Romanded from El 4 Reinstated or CI 5 Transferred from El 6 Multidistriet 8 Multidistrict Proceeding State Court Appellate Court Reopened Another District Litigation Litigation (specify) ?I?ransfer Direct File Cite the US. Civil Statute under which you are filing (Do not cite jurisdictional statutes airless divem?i?d: 28 USC Section 1332 Vi' CAUSE OF ACTION Bricfdescription ofcause: Personal injury due to negligence of Defendants VII. REQUESTED IN [3 CHECK 1F IS A CLASS ACTION DEMAND CHECK YES only if demanded in COMPLAINT: UNDER RULE 23, FRINP. 75,000.00 JURY DEMAND: Yes El No RELATED (See IF ANY JUDGE {g DOCKET NUMBER DATE . .. SIGNATUR . 3A ORNEY . eono?"? (a ii? (Ix-t ME - Wis! Russell J. Pope, Bar No. 03645 FOR OFFICE USE ONLI RECEIPT it AMOUNT APPLYING IFP JUDGE MAG. JUDGE. Case Document 1-1 Filed 06/27/18 Page 2 of 2 44 Reverse (Rev. 16) INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS 44 Authority For Civil Cover Sheet The is 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading 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 ofthc Clerk of Court for the purpose ofinitiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk of Court for each civil complaint filed. The attorney filing a case should complete the form as follows: Plaintiffs-Defendants. Enter names (last, ?rst, middle initial) of plaintiff and defendant. if the plaintiff or defendant is a government agency, use only the full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and then the of?cial, giving both name and title. County of Residence. For each civil case ?led, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at the time of ?ling. in US. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: in land condemnation cases, the county of residence of the "defendant" is the location of the tract of land involved.) Attorneys. Enter the firm name, address, telephone number, and attorney of record. If there are several attorneys, list them on an attachment, noting in this section "(see attachment)". II. Jurisdiction. The basis of jurisdiction is set forth under Rule which requires thatjurisdictions be shown in pleadings. Place an in one of the boxes. If there is more than one basis ofjurisdietion, precedence is given in the order shown below. United States plaintiff. Jurisdiction based on 28 U.S.C. i345 and i348. Suits by agencies and of?cers of the United States are included here. United States defendant. (2) When the plaintiff is suing the United States, its of?cers or agencies, place an in this box. Federal question. (3) This refers to suits under 28 U.S.C. I331, wherejurisdiction arises under the Constitution of the United States, an amendment to the Constitution, an act of Congress or a treaty of the United States. in cases where the US. is a party, the US. plaintiff or defendant code takes precedence, and box or 2 should be marked. Diversity of citizenship. (4) This refers to suits under 28 U.S.C. 1332, where parties are citizens of different states. When Box 4 is checked, the citizenship of the different parties must be checked. (See Section below; NOTE: federal question actions take precedence over diversity cases.) It]. Residence (citizenship) of Principal Parties. This section completed if diversity of citizenship was indicated above. Mark this section for each principal party. IV. Nature of Suit. Place an in the appropriate box. If the nature of suit cannot be determined, be sure the cause of action, in Section VI below, is suf?cient to enable the deputy clerk or the statistical clerk(s) in the Administrative Office to determine the nature of suit. If the cause tits more than one nature of suit, select the most de?nitive. V. Origin. Place an in one of the seven boxes. Original Proceedings. (1) Cases which originate in the United States district courts. Removed from State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.C., Section 1441. When the petition for removal is granted, check this box. Remanded from Appellate Court. (3) Check this box for cases remanded to the district court for further action. Use the date of remand as the filing date. Reinstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date. Transferred from Another District. (5) For cases transferred under Title 28 U.S.C. Section 1404(a). Do not use this for within district transfers or multidistrict litigation transfers. Multidistrict Litigation Transfer. (6) Check this box when a multidistrict case is transferred into the district under authority of Title 28 U.S.C. Section 140?. Multidistrict Litigation Direct File. (8) Check this box when a multidistrict case is filed in the same district as the Master MDL docket. NOTE THAT THERE IS NOT AN ORIGIN CODE 7. Origin Code 7 was used for historical records and is no longer relevant due to changes in statue. VI. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. Do not cite jurisdictional statutes unless diversity. Example: US. Civil Statute: 47 USC 553 Brief Description: Unauthorized reception of cable service VII. Requested in Complaint. Class Action. Place an in this box ifyou are ?iing a class action under Rule 23, Demand. In this space enter the actual dollar amount being demanded or indicate other demand, such as a preliminary injunction. Jury Demand. Check the appropriate box to indicate whether or not a jury is being demanded. Related Cases. This section of the 44 is used to reference related pending cases, if any. if there are related pending cases, insert the docket numbers and the corresponding judge names for such cases. Date and Attorney Signature. Date and sign the civil cover sheet. Case 1:18-cv-01943-DKC Document 1-2 Filed 06/27/18 Page 1 of 2 AO 440 (Rev. 06/12) Summons in a Civil Action UNITED STATES DISTRICT COURT for the District of Maryland __________ District of __________ JARED T. BREEN Plaintiff(s) v. 7TH INNING STRETCH, LP, et al. Defendant(s) ) ) ) ) ) ) ) ) ) ) ) ) Civil Action No. SUMMONS IN A CIVIL ACTION To: (Defendant’s name and address) 7th INNING STRETCH, LP SERVE ON: Chris Bitters, Resident Agent 6400 Hobbs Road Salisbury, Maryland 21804 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: Russell J. Pope, Esquire TREANOR POPE & HUGHES, P.A. 500 York Road Towson, Maryland 21204 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-cv-01943-DKC Document 1-2 Filed 06/27/18 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: Print Save As... Reset . Case 1:18-cv-01943-DKC Document 1-3 Filed 06/27/18 Page 1 of 2 AO 440 (Rev. 06/12) Summons in a Civil Action UNITED STATES DISTRICT COURT for the District of Maryland __________ District of __________ JARED T. BREEN Plaintiff(s) v. 7TH INNING STRETCH, LP, et al. Defendant(s) ) ) ) ) ) ) ) ) ) ) ) ) Civil Action No. SUMMONS IN A CIVIL ACTION To: (Defendant’s name and address) WICOMICO COUNTY, MARYLAND SERVE ON: R. Wayne Strausburg Government Office Building 125 North Division Street Salisbury, Maryland 21801 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: Russell J. Pope, Esquire TREANOR POPE & HUGHES, P.A. 500 York Road Towson, Maryland 21204 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-cv-01943-DKC Document 1-3 Filed 06/27/18 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: Print Save As... Reset .