IN THE UNITED STATES DISTRICT COURT

FOR THE WESTERN DISTRICT OF PENNSYLVANIA

LESLIE FRIEND,

Plaintiff,

v.

KEYSTONE PRETZELS and LAUREL
HILL FOODS, INC.,

Defendants.
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)
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)
)
)
)
)
)
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Civil Action





Electronically Filed

JURY TRIAL DEMANDED


COMPLAINT AND DEMAND FOR JURY TRIAL

Plaintiff Leslie Friend (hereinafter, Ms. Friend), by and through her undersigned
counsel, hereby alleges the following against Defendants Laurel Hill Foods, Inc. and Keystone
Pretzels (hereinafter, Laurel Hill and Keystone):
THE PARTIES
1. Ms. Friend, an individual, is a citizen of the United States residing in Pittsburgh,
PA.
2. Upon information and belief, Laurel Hill is a Massachusetts corporation having its
principal place of business located at 71 Hampden Road, Suite 100, Mansfield, MA 02048.
3. Upon information and belief, Keystone is a Pennsylvania business with its
principal place of business located at 124 West Airport Road, Lititz, PA 17543.
JURISDICTION AND VENUE
4. Ms. Friend brings this action under the Patent Laws of the United States, Title 35
of the United States Code. This Court has jurisdiction pursuant to 28 U.S.C. 1331 and 1338.
Case 2:13-cv-01028-DSC Document 1 Filed 07/17/13 Page 1 of 5
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5. Ms. Friend is the owner of all right, title, and interest in United States Patent No.
D423,184 (the 184 Patent). A true and correct copy of the 184 Patent is attached hereto as
Exhibit A.
6. Upon information and belief, Keystone regularly conducts business in this district,
at least by its website, http://www.keystonepretzels.com/order-our-pretzels/, which is accessible
over the Internet all over the United States, including in this judicial district, and does not purport
to preclude potential customers within this judicial district from obtaining its products or
services.
7. Laurel Hill advertises its Pretzel Chips products via its website at
http://laurelhillfoods.com/pretzel-chips/, which is accessible over the Internet all over the United
States, including in this judicial district, and does not purport to preclude potential customers
within this judicial district from obtaining any Laurel Hill products or services.
8. Laurel Hill, at its website, http://laurelhillfoods.com/buy-our-chips/#, directs
consumers to an Amazon.com website from which the Pretzel Chips products may be purchased.
The Amazon.com website is accessible over the Internet all over the United States, including in
this judicial district, and does not purport to preclude potential customers within this judicial
district from obtaining any Laurel Hill products or services.
9. Laurel Hill, at http://laurelhillfoods.com/buy-our-chips/#, informs consumers of a
selection of retail establishments selling Laurel Hill products. Of the selected retail
establishments listed at http://laurelhillfoods.com/buy-our-chips/#, at least Whole Foods Market
regularly conducts business in this judicial district.
10. Upon information and belief, the Pretzel Chips products have been offered for
sale and/or sold in this district.
Case 2:13-cv-01028-DSC Document 1 Filed 07/17/13 Page 2 of 5
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11. Venue is proper pursuant to 28 U.S.C. 1391 and 1400.
SUMMARY OF THE FACTS
12. The 184 Patent claims an ornamental design for a pretzel resembling a peace
symbol.
13. Upon information and belief, Keystone makes, sells, and offers to sell pretzel
products. Upon information and belief, Keystone makes and sells to Laurel Hill the Pretzel
Chips for Laurel Hill to, in turn, sell and offer for sale.
14. The shape of Laurel Hills Pretzel Chips resembles a peace symbol. True and
correct copies of pages from Laurel Hills website showing Laurel Hills Pretzel Chips are
attached hereto as Exhibit B.
15. Upon information and belief, Keystone continues to make, offer for sale, and sell
Pretzel Chips to Laurel Hill, and Laurel Hill continues to sell and offer for sale its Pretzel Chips.
COUNT I:
INFRINGEMENT OF THE 184 PATENT

16. Ms. Friend repeats and re-alleges each an every averment contained in paragraphs
1-15 hereof as if fully set forth herein.
17. Keystone has infringed the 184 Patent at least by making, selling, and offering to
sell, and by inducing, aiding, and abetting, actively inducing, and encouraging and contributing
to others sales and offers to sell at least the following pretzel products: (1) Everything Laurel
Hill Pretzel Chips, (2) Sea Salt Laurel Hill Pretzel Chips, and (3) Honey Multigrain Laurel Hill
Pretzel Chips. Keystone received notice of the 184 Patent at least as early as April 11, 2013.
18. Laurel Hill has infringed the 184 Patent at least by selling and offering to sell,
and by inducing, aiding, and abetting, actively inducing, and encouraging and contributing to
others sales, offers to sell, and use of at least the following pretzel products: (1) Everything
Case 2:13-cv-01028-DSC Document 1 Filed 07/17/13 Page 3 of 5
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Laurel Hill Pretzel Chips, (2) Sea Salt Laurel Hill Pretzel Chips, and (3) Honey Multigrain
Laurel Hill Pretzel Chips. Laurel Hill received notice of the 184 Patent at least as early as April
10, 2013.
19. Keystones and Laurel Hills infringement has injured Ms. Friend, and Ms. Friend
is entitled to recover damages adequate to compensate for the infringement that has occurred.
Ms. Friend is entitled to recover at least a reasonable royalty pursuant to 35 U.S.C. 284.
Additionally and alternatively, Ms. Friend is entitled to recover Keystone and Laurel Hills total
profit attributable to the infringing pretzel products pursuant to 35 U.S.C. 289.
20. Upon information and belief, Keystone and Laurel Hill have been infringing the
184 Patent since at least the 2011 time frame. Keystone and Laurel Hill have infringed the 184
Patent with knowledge of the patent and without legal justification or excuse at least since April
11, 2013 and April 10, 2013, respectively. Keystone and Laurel Hills infringement from these
times forward has been and is willful.
21. Ms. Friend has been injured and is being injured by Keystone and Laurel Hills
infringement of the 184 Patent, and Ms. Friend will continue to suffer irreparable harm unless
Keystone and Laurel Hills infringement of the 184 Patent is enjoined by this Court.
WHEREFORE, Ms. Friend respectfully requests judgment be entered against Keystone
and Laurel Hill as follows:
A. An award of damages adequate to compensate Ms. Friend for the infringement, in
the form of at least a reasonable royalty, and/or Keystone and Laurel Hills total profit together
with prejudgment interest from the date the infringement began;
B. Any damages permitted in the Courts equitable discretion, including increased
damages for willful infringement under 35 U.S.C. 284;
Case 2:13-cv-01028-DSC Document 1 Filed 07/17/13 Page 4 of 5
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C. A finding that this case is exceptional and an award to Ms. Friend of her
attorneys fees and expenses as provided by 35 U.S.C. 285;
D. An injunction permanently enjoining Keystone and Laurel Hill, and all persons in
active concert or participation with Keystone and Laurel Hill, from further acts of infringement
of the 184 Patent; and
E. Such other and further relief as this court deems proper.
DEMAND FOR JURY TRIAL
Pursuant to Rule 38 of the Federal Rules of Civil Procedure, ms. Friend hereby demands
a trial by jury of all issues triable by jury.
Respectfully submitted,

Dated: J uly 17, 2013 s/Russell D. Orkin
Russell D. Orkin (PA ID No. 01331)
rorkin@webblaw.com
Daniel H. Brean (PA ID No. 208711)
dbrean@webblaw.com

THE WEBB LAW FIRM
One Gateway Center
420 Fort Duquesne Blvd., Suite 1200
Pittsburgh, PA 15222
412.471.8815
412.471.4094 (fax)

Counsel for Plaintiff Leslie Friend
Case 2:13-cv-01028-DSC Document 1 Filed 07/17/13 Page 5 of 5
JS 44 (Rev. 12/12)
CIVIL COVER SHEET
The JS 44 civil cover sheet and the inIormation contained herein neither replace nor supplement the Iiling and service oI pleadings or other papers as required by law, except as
provided by local rules oI court. This Iorm, approved by the Judicial ConIerence oI the United States in September 1974, is required Ior the use oI the Clerk oI Court Ior the
purpose oI initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.)
I. (a) PLAINTIFFS DEFENDANTS
(b) County oI Residence oI First Listed PlaintiII County oI Residence oI First Listed DeIendant
(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, and Telephone Number) Attorneys (If Known)
II. BASIS OF JURISDICTION (Place an X in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an X in One Box for Plaintiff
(For Diversity Cases Only) and One Box for Defendant)
u 1 U.S. Government u 3 Federal Question PTF DEF PTF DEF
PlaintiII (U.S. Government Not a Party) Citizen oI This State u 1 u 1 Incorporated or Principal Place u 4 u 4
oI Business In This State
u 2 U.S. Government u 4 Diversity Citizen oI Another State u 2 u 2 Incorporated and Principal Place u 5 u 5
DeIendant (Indicate Citizenship of Parties in Item III) oI Business In Another State
Citizen or Subject oI a u 3 u 3 Foreign Nation u 6 u 6
Foreign Country
IV. NATURE OF SUIT (Place an X in One Box Only)
CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES
u 110 Insurance PERSONAL INJURY PERSONAL INJURY u 625 Drug Related Seizure u 422 Appeal 28 USC 158 u 375 False Claims Act
u 120 Marine u 310 Airplane u 365 Personal Injury - oI Property 21 USC 881 u 423 Withdrawal u 400 State Reapportionment
u 130 Miller Act u 315 Airplane Product Product Liability u 690 Other 28 USC 157 u 410 Antitrust
u 140 Negotiable Instrument Liability u 367 Health Care/ u 430 Banks and Banking
u 150 Recovery oI Overpayment u 320 Assault, Libel & Pharmaceutical PROPERTY RIGHTS u 450 Commerce
& EnIorcement oI Judgment Slander Personal Injury u 820 Copyrights u 460 Deportation
u 151 Medicare Act u 330 Federal Employers` Product Liability u 830 Patent u 470 Racketeer InIluenced and
u 152 Recovery oI DeIaulted Liability u 368 Asbestos Personal u 840 Trademark Corrupt Organizations
Student Loans u 340 Marine Injury Product u 480 Consumer Credit
(Excludes Veterans) u 345 Marine Product Liability LABOR SOCIAL SECURITY u 490 Cable/Sat TV
u 153 Recovery oI Overpayment Liability PERSONAL PROPERTY u 710 Fair Labor Standards u 861 HIA (1395II) u 850 Securities/Commodities/
oI Veteran`s BeneIits u 350 Motor Vehicle u 370 Other Fraud Act u 862 Black Lung (923) Exchange
u 160 Stockholders` Suits u 355 Motor Vehicle u 371 Truth in Lending u 720 Labor/Management u 863 DIWC/DIWW (405(g)) u 890 Other Statutory Actions
u 190 Other Contract Product Liability u 380 Other Personal Relations u 864 SSID Title XVI u 891 Agricultural Acts
u 195 Contract Product Liability u 360 Other Personal Property Damage u 740 Railway Labor Act u 865 RSI (405(g)) u 893 Environmental Matters
u 196 Franchise Injury u 385 Property Damage u 751 Family and Medical u 895 Freedom oI InIormation
u 362 Personal Injury - Product Liability Leave Act Act
Medical Malpractice u 790 Other Labor Litigation u 896 Arbitration
REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS u 791 Employee Retirement FEDERAL TAX SUITS u 899 Administrative Procedure
u 210 Land Condemnation u 440 Other Civil Rights Habeas Corpus: Income Security Act u 870 Taxes (U.S. PlaintiII Act/Review or Appeal oI
u 220 Foreclosure u 441 Voting u 463 Alien Detainee or DeIendant) Agency Decision
u 230 Rent Lease & Ejectment u 442 Employment u 510 Motions to Vacate u 871 IRSThird Party u 950 Constitutionality oI
u 240 Torts to Land u 443 Housing/ Sentence 26 USC 7609 State Statutes
u 245 Tort Product Liability Accommodations u 530 General
u 290 All Other Real Property u 445 Amer. w/Disabilities - u 535 Death Penalty IMMIGRATION
Employment Other: u 462 Naturalization Application
u 446 Amer. w/Disabilities - u 540 Mandamus & Other u 465 Other Immigration
Other u 550 Civil Rights Actions
u 448 Education u 555 Prison Condition
u 560 Civil Detainee -
Conditions oI
ConIinement
V. ORIGIN (Place an X in One Box Only)
u 1 Original
Proceeding
u 2 Removed Irom
State Court
u 3 Remanded Irom
Appellate Court
u 4 Reinstated or
Reopened
u 5 TransIerred Irom
Another District
(specify)
u 6 Multidistrict
Litigation
VI. CAUSE OF ACTION
Cite the U.S. Civil Statute under which you are Iiling (Do not cite jurisdictional statutes unless diversity):

BrieI description oI cause:
VII. REQUESTED IN
COMPLAINT:
u CHECK IF THIS IS A CLASS ACTION
UNDER RULE 23, F.R.Cv.P.
DEMAND $ CHECK YES only iI demanded in complaint:
JURY DEMAND: u Yes u No
VIII. RELATED CASE(S)
IF ANY
(See instructions):
JUDGE DOCKET NUMBER
DATE SIGNATURE OF ATTORNEY OF RECORD
FOR OFFICE USE ONLY
RECEIPT # AMOUNT APPLYING IFP JUDGE MAG. JUDGE
LESLIE FRIEND
Allegheny
Russell D. Orkin and Daniel H. Brean, The Webb Law Firm, One
Gateway Center, 420 Fort Duquesne Blvd., Suite 1200, Pittsburgh, PA
15222; 412.471.8815
KEYSTONE PRETZELS and LAUREL HILL FOODS, INC.
Lancaster
Title 35 of the United States Code
Patent Infringement
07/17/2013 s/Russell D. Orkin
Case 2:13-cv-01028-DSC Document 1-1 Filed 07/17/13 Page 1 of 2
JS 44AREVISED June, 2009
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA
THIS CASE DESIGNATION SHEET MUST BE COMPLETED
PART A
This case belongs on the ( Erie Johnstown Pittsburgh) calendar.
1. ERIE CALENDAR - If cause of action arose in the counties of Crawford, Elk, Erie,
Forest, McKean. Venang or Warren, OR any plaintiff or defendant resides in one of said
counties.
2. JOHNSTOWN CALENDAR - If cause of action arose in the counties of Bedford, Blair,
Cambria, Clearfield or Somerset OR any plaintiff or defendant resides in one of
said counties.
3. Complete if on ERIE CALENDAR: I certify that the cause of action arose in
County and that the resides in County.
4. Complete if on JOHNSTOWN CALENDAR: I certify that the cause of action arose in
County and that the resides in County.
PART B (You are to check ONE of the following)
1. This case is related to Number . Short Caption .
2. This case is not related to a pending or terminated case.
DEFINlTIONS OF RELATED CASES:
CIVIL: Civil cases are deemed related when a case filed relates to property included in
another suit or involves the same issues of fact or it grows out of the same transactions
as another suit or involves the validity or infringement of a patent involved in another
suit EMINENT DOMAIN: Cases in contiguous closely located groups and in common ownership
groups which will lend themselves to consolidation for trial shall be deemed related.
HABEAS CORPUS & CIVIL RIGHTS: All habeas corpus petitions filed by the same individual
shall be deemed related. All pro se Civil Rights actions by the same individual shall be
deemed related.
PARTC
I. CIVIL CATEGORY (Place x in only applicable category).
1. Antitrust and Securities Act Cases
2. Labor-Management Relations
3. Habeas corpus
4. Civil Rights
5. Patent, Copyright, and Trademark
6. Eminent Domain
7. All other federal question cases
8.

All personal and property damage tort cases, including maritime, FELA,
Jones Act, Motor vehicle, products liability, assault, defamation, malicious
prosecution, and false arrest
9. Insurance indemnity, contract and other diversity cases.
10. Government Collection Cases (shall include HEW Student Loans (Education),
V A 0verpayment, Overpayment of Social Security, Enlistment
Overpayment (Army, Navy, etc.), HUD Loans, GAO Loans (Misc. Types),
Mortgage Foreclosures, SBA Loans, Civil Penalties and Coal Mine
Penalty and Reclamation Fees.)
I certify that to the best of my knowledge the entries on this Case Designation
Sheet are true and correct
Date:
ATTORNEY AT LAW
NOTE: ALL SECTIONS OF BOTH FORMS MUST BE COMPLETED BEFORE CASE CAN BE PROCESSED.
07/17/2013
s/Russell D. Orkin
Case 2:13-cv-01028-DSC Document 1-1 Filed 07/17/13 Page 2 of 2






















Exhibit A
Case 2:13-cv-01028-DSC Document 1-2 Filed 07/17/13 Page 1 of 3
Case 2:13-cv-01028-DSC Document 1-2 Filed 07/17/13 Page 2 of 3
Case 2:13-cv-01028-DSC Document 1-2 Filed 07/17/13 Page 3 of 3






















Exhibit B
Case 2:13-cv-01028-DSC Document 1-3 Filed 07/17/13 Page 1 of 4
VIEW NUTRITIONAL INFO
EVERYTHING
Bursting with savory sesame, garlic, poppy seed and onionthis pretzel is fully
loaded with flavor. Mouthwatering crunch, thinly baked and downright
delicious!
INGREDIENTS
Wheat Flour, Malt Extract, Sea
Salt, Canola Oil, Sesame
Seeds, Dehydrated Onion,
Dehydrated Garlic, Poppy Seed,
Vegetable Fiber, Yeast, Soda.
Produced in a facility that also
handles soy products, nut free.
EVERYTHING HONEY MULTIGRAIN SEA SALT
CONNECT WITH US BUY OUR CHIPS SELL OUR CHIPS CONTACT SIGN UP
PRETZEL CHIPS TORTILLA CHIPS POTATO CHIPS THE BUZZ OUR OTHER PRODUCTS ABOUT US
Page 1 of 1 Everything | Laurel Hill
6/28/2013 http://laurelhillfoods.com/chips/pretzel-chips/everything/
Case 2:13-cv-01028-DSC Document 1-3 Filed 07/17/13 Page 2 of 4
VIEW NUTRITIONAL INFO
HONEY MULTIGRAIN
We have added a touch of honey to our multigrain recipe to make this pretzel
chip a taste sensation. Mouthwatering crunch, thinly baked and downright
delicious!
INGREDIENTS
Wheat Flour, Multigrain Flour
(Oat Flour, Rye Flour, Ground
Whole Wheat), Honey, Malt,
Sea Salt, Canola Oil, Vegetable
Fiber, Yeast, Soda.
Produced in a facility that also
handles soy products, nut free.
EVERYTHING HONEY MULTIGRAIN SEA SALT
CONNECT WITH US BUY OUR CHIPS SELL OUR CHIPS CONTACT SIGN UP
PRETZEL CHIPS TORTILLA CHIPS POTATO CHIPS THE BUZZ OUR OTHER PRODUCTS ABOUT US
Page 1 of 1 Honey Multigrain | Laurel Hill
6/28/2013 http://laurelhillfoods.com/chips/pretzel-chips/honey-multigrain/
Case 2:13-cv-01028-DSC Document 1-3 Filed 07/17/13 Page 3 of 4
VIEW NUTRITIONAL INFO
SEA SALT
We have added a touch of salt to our pretzel recipe voila A (soon to be)
classic Mouthwatering crunch, thinly baked and downright delicious!
INGREDIENTS
Wheat Flour, Malt Extract, Seas
Salt, Canola Oil, Vegetable
Fiber, Yeast, Soda.
Produced in a facility that also
handles soy products, nut free.
EVERYTHING HONEY MULTIGRAIN SEA SALT
CONNECT WITH US BUY OUR CHIPS SELL OUR CHIPS CONTACT SIGN UP
PRETZEL CHIPS TORTILLA CHIPS POTATO CHIPS THE BUZZ OUR OTHER PRODUCTS ABOUT US
Page 1 of 1 Sea Salt | Laurel Hill
6/28/2013 http://laurelhillfoods.com/chips/pretzel-chips/sea-salt-2/
Case 2:13-cv-01028-DSC Document 1-3 Filed 07/17/13 Page 4 of 4
AO 440 (Rev. 06/12) Summons in a Civil Action
UNITED STATES DISTRICT COURT
for the
__________ District of __________
)
)
)
)
)
)
)
)
)
)
)
)
Plaintiff(s)
v. Civil Action No.
Defendant(s)
SUMMONS IN A CIVIL ACTION
To: (Defendants name and address)
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 plaintiffs attorney,
whose name and address are:
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 2:13-cv-01028-DSC Document 1-4 Filed 07/17/13 Page 1 of 2
Western District of Pennsylvania
LESLIE FRIEND
KEYSTONE PRETZELS and LAUREL HILL FOODS,
INC.
Keystone Pretzels
124 West Airport Road
Lititz, PA 17543
Russell D. Orkin
The Webb Law Firm
One Gateway Center
420 Fort Duquesne Blvd., Suite 1200
Pittsburgh, PA 15222
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 individuals 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 individuals 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 $ .
I declare under penalty of perjury that this information is true.
Date:
Servers signature
Printed name and title
Servers address
Additional information regarding attempted service, etc:
Case 2:13-cv-01028-DSC Document 1-4 Filed 07/17/13 Page 2 of 2
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AO 440 (Rev. 06/12) Summons in a Civil Action
UNITED STATES DISTRICT COURT
for the
__________ District of __________
)
)
)
)
)
)
)
)
)
)
)
)
Plaintiff(s)
v. Civil Action No.
Defendant(s)
SUMMONS IN A CIVIL ACTION
To: (Defendants name and address)
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 plaintiffs attorney,
whose name and address are:
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 2:13-cv-01028-DSC Document 1-5 Filed 07/17/13 Page 1 of 2
Western District of Pennsylvania
LESLIE FRIEND
KEYSTONE PRETZELS and LAUREL HILL FOODS,
INC.
Laurel Hill Foods, Inc.
71 Hampden Road, Suite 100
Mansfield, MA 02048
Russell D. Orkin
The Webb Law Firm
One Gateway Center
420 Fort Duquesne Blvd., Suite 1200
Pittsburgh, PA 15222
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 individuals 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 individuals 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 $ .
I declare under penalty of perjury that this information is true.
Date:
Servers signature
Printed name and title
Servers address
Additional information regarding attempted service, etc:
Case 2:13-cv-01028-DSC Document 1-5 Filed 07/17/13 Page 2 of 2
0.00
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