New York Affidavit of Service Form
This form will be used by the person serving the copies of divorce papers to the Defendant. This form verifies that the Defendant received all necessary papers as required for disclosure. File this form after its completion with the court clerk’s office.
SUPREME COURT OF THE STATE OF NEW YORK
1 COUNTY OF
3 Plaintiff, Index No.:
AFFIDAVIT OF SERVICE
5 STATE OF }
COUNTY OF }
6 ______________________________ being duly sworn, says:
7 1. I am not a party to the action, am over 18 years of age and reside at:
8 2. On__________________, at ____a.m./p.m. at ________________________________
_________________________________________ I served the . summons with
notice OR . summons and verified complaint, and the notice of automatic orders,
on ____________________________, the Defendant named by delivering a true
copy to the Defendant personally.
. In addition I served a copy of the Child Support Standards Chart.
. In addition I served a copy of the Notice of Continuation of Health Care Coverage
3. The notice required by the Domestic Relations Law, Section 232 — “ACTION FOR A
DIVORCE” — was legibly printed on the face of the summons served on the Defendant.
9 4. I knew the person so served to be the person described in the summons as the Defendant.
My knowledge of the Defendant and how I acquired it is as follows: (select one)
. I have known the defendant for _______ years and____________________
. I identified the Defendant by a photograph annexed to this affidavit and which was
given to me by the Plaintiff.
. Plaintiff accompanied me and pointed out the Defendant.
. I asked the person served if he/she was the person named in the summons and
Defendant admitted being the person so named.
(Form UD-3 – Rev. 9/11)
5. Deponent describes the individual served as follows:
Sex Height Weight Age Color of Skin Color of Hair
. Under 5’
. Over 6′
. Under 100 Lbs.
. 100-130 Lbs.
. 131-160 Lbs.
. 161-200 Lbs.
. Over 200 Lbs.
. 14-17 Yrs.
. 18-20 Yrs.
. 21-35 Yrs.
. 36-50 Yrs.
. 51-65 Yrs.
. Over 65 Yrs.
Other identifying features, if any:___________________________________________________.
10 . 6a. At the time I served the Defendant, I asked him/her if he/she was in the military service of this
state, any other state, or this nation, and the Defendant responded in the negative.
.6b. The Defendant stated that he/she is in the following military service .
.6c. The Defendant refused to answer.
Subscribed and Sworn to
before me on
(Form UD-3 – Rev. 9/11)