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Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 1 of 11 PageID #: 1

UNITED STATES DISTRICT COURT


EASTERN DISTRICT OF NEW YORK
----------------------------------------------------------------------- x
ROGER ARTHUR,
Plaintiff,
COMPLAINT
-againstTHE CITY OF NEW YORK, POLICE OFFICER
ANTHONY DENATALE (tax # 952282), POLICE
OFFICER STEVEN COSENTINO (tax # 948816 ),
DETECTIVE MICHAEL BURKE (tax # 929800),
DETECTIVE JOHN DOE,

Jury Trial Demanded

Defendants.
----------------------------------------------------------------------- x
PRELIMINARY STATEMENT
1.

This is a civil rights action in which the plaintiff alleges that the City of

New York and four New York City Police Officers of the 121st Precinct in Staten Island violated
his rights under 42 U.S.C. 1983 and the Fourth and Sixth Amendments to the United States
Constitution by falsely arresting him, using unreasonable force on him, denying him a fair trial
and maliciously prosecuting him. Plaintiff also asserts claims of false arrest, assault, battery,
malicious prosecution and vicarious liability under New York state law. Plaintiff seeks
compensatory and punitive damages, attorneys fees and costs, and such other and further relief
as the Court deems just and proper.
JURISDICTION & VENUE
2.

This action is brought pursuant to 42 U.S.C. 1983 and the Fourth and

Sixth Amendments to the United States Constitution. Jurisdiction is conferred upon this Court
by 28 U.S.C. 1331 and 1343.

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 2 of 11 PageID #: 2

3.

Plaintiff invokes the supplemental jurisdiction of this Court pursuant to 28

U.S.C. 1367 to hear and decide his New York state law claims of false arrest, assault, battery,
malicious prosecution and vicarious liability which form part of the same case and controversy
as plaintiffs federal claims under Article III of the United States Constitution.
4.

Venue is proper in the Eastern District of New York pursuant to 28 U.S.C.

1391(b) and (c) because the City of New York is located in this District and because the
incident in question occurred in this District.
JURY TRIAL
5.

Pursuant to Fed. R. Civ. P. 38, plaintiff demands a jury trial.


NOTICE OF CLAIM

6.

In connection with plaintiffs claims of false arrest, assault, battery,

malicious prosecution and vicarious liability brought under New York state law, a notice of
claim and an amended notice of claim were duly filed with the City of New York within 90 days
of the incident at issue, more than 30 days have elapsed since such filings, and the City has not
offered to settle plaintiffs state law claims.
7.

This action is brought within one year and 90 days of the incident at issue.
PARTIES

8.

Plaintiff is a resident of the State of New York, County of Richmond.

9.

The City of New York is a municipal corporation organized under the

laws of the State of New York.


10.

The individual defendants are members of the NYPD. The individual

defendants acted under color of state law and within the scope of their employment as members

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of the NYPD at all relevant times herein. The individual defendants are sued in their individual
capacities.
STATEMENT OF FACTS
11.

On May 7, 2015, at approximately 10:00 p.m., plaintiff was the victim of a

gunpoint robbery and shooting that took place on Sharpe Avenue in Staten Island, New York.
12.

Plaintiff was taken by ambulance to Richmond University Medical Center

located at 355 Bard Avenue to receive treatment for his injuries.


13.

At the hospital, NYPD Officer Anthony Denatale, NYPD Officer Steven

Cosentino, NYPD Detective Michael Burke and an unidentified NYPD detective (collectively,
the defendants) of the 121st Precinct interviewed plaintiff about the robbery.
14.

At the hospital, the defendants also interviewed Seymour Gray, whom

plaintiff did not know, who was the victim of a gunpoint robbery at a different time and location
by apparently the same individuals who had robbed and assaulted plaintiff.
15.

The defendants became frustrated by plaintiffs and Grays inability to

identify their assailants and thought that they were being intentionally uncooperative.
16.

A verbal disputed followed.

17.

During the verbal dispute, Officer Steven Cosentino lunged at Gray and

accidentally slipped and fell.


18.

The enraged defendants subsequently arrested plaintiff and Gray and took

them to the 121st Precinct.


19.

During the course of arresting plaintiff, Detective John Doe, maliciously

and without legal justification, twisted plaintiffs left arm, pushed plaintiff and forced him to

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 4 of 11 PageID #: 4

stand on his injured leg, causing plaintiff pain and physical injury. At all times at the hospital,
plaintiff was compliant and did not resist arrest.
20.

At the 121st Precinct, the defendants, acting in concert, fabricated a story

that plaintiff and Gray, acting together, pushed Officer Cosentino to the ground. Based on this
fabrication, the defendants falsely charged plaintiff with assaulting and harassing Cosentino.
21.

Plaintiff was eventually returned to Richmond University Medical Center

to receive additional medical treatment and, after receiving treatment, plaintiff was taken to
Staten Island Central Booking.
22.

While plaintiff was incarcerated in Central Booking, the defendants,

acting in concert, misrepresented to the Richmond County District Attorneys Office that
plaintiff had assaulted and harassed Officer Cosentino at Richmond University Medical Center.
23.

In furtherance of having plaintiff prosecuted, Officer Denatale, with the

approval of the other defendants, signed a criminal court complaint falsely alleging that plaintiff
was involved in pushing Officer Cosentino to the ground and falsely charging plaintiff with
assault and harassment.
24.

On May 8, 2015, at approximately 5:00 p.m., plaintiff was arraigned in

Criminal Court, Richmond County.


25.

The presiding judge released plaintiff on his own recognizance and

adjourned plaintiffs case until June 8, 2015.


26.

On May 12, 2015, plaintiff hired a criminal defense attorney at a cost of

27.

On May 15, 2015, the Richmond County District Attorney's Office

$2,600.

advanced plaintiffs criminal case and dismissed all charges.


4

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28.

Defendants illegal conduct caused plaintiff to suffer a loss of liberty,

emotional distress, fear, anxiety, humiliation, embarrassment, pain, physical injuries and
financial loss.
FIRST CLAIM
( 1983; FALSE ARREST)
(Against All Defendants)
29.

Plaintiff repeats the foregoing allegations.

30.

Defendants, acting under color of state law, arrested and imprisoned

plaintiff without legal justification or probable cause in violation of 1983 and the Fourth
Amendment.
31.

Defendants intended to confine the plaintiff, plaintiff was conscious of his

confinement, plaintiff did not consent to his confinement, and plaintiffs confinement was not
privileged or lawful.
32.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


33.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


SECOND CLAIM
( 1983; UNREASONABLE FORCE)
(Against Detective John Doe)
34.

Plaintiff repeats the foregoing allegations.

35.

Detective John Doe, acting under color of state law, used force upon

plaintiff which was objectively unreasonable in violation of 1983 and the Fourth Amendment.
5

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 6 of 11 PageID #: 6

36.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


37.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


THIRD CLAIM
( 1983; MALICIOUS PROSECUTION)
(Against All Defendants)
38.

Plaintiff repeats the foregoing allegations.

39.

Defendants, acting under color of state law, maliciously misrepresented to

prosecutors that plaintiff had violated the law and initiated a prosecution against plaintiff which
terminated in plaintiffs favor.
40.

Defendants conduct violated 1983 and the Fourth Amendment.

41.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


42.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


FOURTH CLAIM
( 1983; DENIAL OF A FAIR TRIAL)
(Against All Defendants)
43.

Plaintiff repeats the foregoing allegations.

44.

Defendants, acting under color of state law, maliciously misrepresented to

prosecutors that plaintiff had violated the law in violation of 1983 and the Sixth Amendment.

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 7 of 11 PageID #: 7

45.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


46.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


FIFTH CLAIM
( 1983; FAILURE TO INTERVENE)
(Against All Defendants)
47.

Plaintiff repeats the foregoing allegations.

48.

Defendants, while acting under color of state law, had a reasonable

opportunity to prevent the violations of plaintiffs constitutional rights under the Fourth and
Sixth Amendments, but they failed to fulfill their constitutional obligation to intervene.
49.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


50.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


SIXTH CLAIM
( 1983; MUNICIPAL LIABILITY)
(Against the City of New York)
51.

Plaintiff repeats the foregoing allegations.

52.

The City of New York is a person within the meaning of 42 U.S.C.

53.

The City of New York, through a policy, practice or custom, directly

1983.

caused the constitutional violations suffered by plaintiff.


7

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 8 of 11 PageID #: 8

54.

Upon information and belief, the City of New York, at all relevant times,

was aware that the defendants and other members of the NYPD are unfit officers who have
previously committed acts similar to those alleged herein, have a propensity for unconstitutional
conduct, and/or have been inadequately trained.
55.

Despite having the aforesaid knowledge, the City exercised deliberate

indifference by failing to take remedial action. The City failed to properly investigate prior
allegations of police misconduct made against the defendants and other officers and failed to
properly train, retrain, supervise, discipline and monitor the defendants and other officers like
them.
56.

The Citys failure to act resulted in the violation of plaintiffs

constitutional rights as described herein.


57.

The Citys conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


58.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


SEVENTH CLAIM
(FALSE ARREST/FALSE IMPRISONMENT UNDER N.Y. STATE LAW)
(Against All Defendants)
59.

Plaintiff repeats the foregoing allegations.

60.

Defendants, acting within the scope of their employment as members of

the NYPD, arrested and imprisoned plaintiff without legal justification or probable cause.

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 9 of 11 PageID #: 9

61.

Defendants intended to confine the plaintiff, plaintiff was conscious of his

confinement, plaintiff did not consent to his confinement, and plaintiffs confinement was not
privileged or lawful.
62.

Because the individual defendants were acting within the scope of their

employment when they falsely arrested and imprisoned plaintiff, the City of New York is
vicariously liable to plaintiff.
63.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


64.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


EIGHTH CLAIM
(ASSAULT UNDER N.Y. STATE LAW)
(Against Detective John Doe)
65.

Plaintiff repeats the foregoing allegations.

66.

Detective John Doe, acting within the scope of his employment as a

member of the NYPD, placed plaintiff in fear of imminent harmful and offensive physical
contacts which injured plaintiff.
67.

Because Detective John Doe was acting within the scope of his

employment when he assaulted plaintiff, the City of New York is vicariously liable to plaintiff.
68.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


69.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial


9

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 10 of 11 PageID #: 10

NINTH CLAIM
(BATTERY UNDER N.Y. STATE LAW)
(Against Detective John Doe)
70.

Plaintiff repeats the foregoing allegations.

71.

Detective John Doe, acting within the scope of his employment as a

member of the NYPD, made offensive and nonconsensual physical contact with plaintiff which
injured plaintiff.
72.

Because Detective John Doe was acting within the scope of his

employment when he battered plaintiff, the City of New York is vicariously liable to plaintiff.
73.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


74.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial


TENTH CLAIM
(MALICIOUS PROSECUTION UNDER N.Y. STATE LAW)
(Against All Defendants)
75.

Plaintiff repeats the foregoing allegations.

76.

Defendants, acting within the scope of their employment as members of

the NYPD, maliciously misrepresented to prosecutors that plaintiff had violated the law and
initiated a prosecution against plaintiff which terminated in plaintiffs favor.
77.

Because the individual defendants were acting within the scope of their

employment when they maliciously prosecuted plaintiff, the City of New York is vicariously
liable to plaintiff.
10

Case 1:15-cv-05267 Document 1 Filed 09/11/15 Page 11 of 11 PageID #: 11

78.

Defendants conduct caused plaintiff to suffer various personal injuries,

including the injuries described herein.


79.

As a result of the foregoing, plaintiff is entitled to compensatory and

punitive damages in an amount to be determined at trial.


WHEREFORE, plaintiff requests the following relief jointly and severally against
the defendants:
a.

Compensatory damages in an amount to be determined by a jury;

b.

Punitive damages in an amount to be determined by a jury;

c.

Attorneys fees and costs;

d.

Such other and further relief as the Court may deem just and proper.

DATED: September 11, 2015

_____/s/___________________________
RICHARD CARDINALE
Attorney at Law
26 Court Street, Suite # 1815
Brooklyn, New York 11242
(718) 624-9391

11

JS 44 (Rev. 1/2013)

Case 1:15-cv-05267 Document 1-1 Filed 09/11/15 Page 1 of 2 PageID #: 12

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.)

I. (a) PLAINTIFFS

DEFENDANTS

Roger Arthur

City of New York, et al.,

(b) County of Residence of First Listed Plaintiff

County of Residence of First Listed Defendant

Richmond

(EXCEPT IN U.S. PLAINTIFF CASES)


NOTE:

(IN U.S. PLAINTIFF CASES ONLY)


IN LAND CONDEMNATION CASES, USE THE LOCATION OF
THE TRACT OF LAND INVOLVED.

Attorneys (If Known)

(c) Attorneys (Firm Name, Address, and Telephone Number)


Richard Cardinale, 26 Court Street, suite 1815, Brooklyn, NY 11242, 718
624 9391

II. BASIS OF JURISDICTION (Place an X in One Box Only)


1

U.S. Government
Plaintiff

Federal Question
(U.S. Government Not a Party)

U.S. Government
Defendant

Diversity
(Indicate Citizenship of Parties in Item III)

III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an X in One Box for Plaintiff


(For Diversity Cases Only)
PTF
Citizen of This State
1

DEF
1

Citizen of Another State

Incorporated and Principal Place


of Business In Another State

Citizen or Subject of a
Foreign Country

Foreign Nation

and One Box for Defendant)


DEF
PTF
Incorporated or Principal Place
4
4
of Business In This State

IV. NATURE OF SUIT (Place an X in One Box Only)


CONTRACT

TORTS

110 Insurance
120 Marine
130 Miller Act
140 Negotiable Instrument
150 Recovery of Overpayment
& Enforcement of Judgment
151 Medicare Act
152 Recovery of Defaulted
Student Loans
(Excludes Veterans)
153 Recovery of Overpayment
of Veterans Benefits
160 Stockholders Suits
190 Other Contract
195 Contract Product Liability
196 Franchise

REAL PROPERTY
210 Land Condemnation
220 Foreclosure
230 Rent Lease & Ejectment
240 Torts to Land
245 Tort Product Liability
290 All Other Real Property

PERSONAL INJURY
310 Airplane
315 Airplane Product
Liability
320 Assault, Libel &
Slander
330 Federal Employers
Liability
340 Marine
345 Marine Product
Liability
350 Motor Vehicle
355 Motor Vehicle
Product Liability
360 Other Personal
Injury
362 Personal Injury Medical Malpractice
CIVIL RIGHTS
440 Other Civil Rights
441 Voting
442 Employment
443 Housing/
Accommodations
445 Amer. w/Disabilities Employment
446 Amer. w/Disabilities Other
448 Education

FORFEITURE/PENALTY

PERSONAL INJURY
365 Personal Injury Product Liability
367 Health Care/
Pharmaceutical
Personal Injury
Product Liability
368 Asbestos Personal
Injury Product
Liability
PERSONAL PROPERTY
370 Other Fraud
371 Truth in Lending
380 Other Personal
Property Damage
385 Property Damage
Product Liability
PRISONER PETITIONS
Habeas Corpus:
463 Alien Detainee
510 Motions to Vacate
Sentence
530 General
535 Death Penalty
Other:
540 Mandamus & Other
550 Civil Rights
555 Prison Condition
560 Civil Detainee Conditions of
Confinement

625 Drug Related Seizure


of Property 21 USC 881
690 Other

BANKRUPTCY
422 Appeal 28 USC 158
423 Withdrawal
28 USC 157
PROPERTY RIGHTS
820 Copyrights
830 Patent
840 Trademark

LABOR
710 Fair Labor Standards
Act
720 Labor/Management
Relations
740 Railway Labor Act
751 Family and Medical
Leave Act
790 Other Labor Litigation
791 Employee Retirement
Income Security Act

SOCIAL SECURITY
861 HIA (1395ff)
862 Black Lung (923)
863 DIWC/DIWW (405(g))
864 SSID Title XVI
865 RSI (405(g))

FEDERAL TAX SUITS


870 Taxes (U.S. Plaintiff
or Defendant)
871 IRSThird Party
26 USC 7609

OTHER STATUTES

375 False Claims Act


400 State Reapportionment
410 Antitrust
430 Banks and Banking
450 Commerce
460 Deportation
470 Racketeer Influenced and
Corrupt Organizations
480 Consumer Credit
490 Cable/Sat TV
850 Securities/Commodities/
Exchange
890 Other Statutory Actions
891 Agricultural Acts
893 Environmental Matters
895 Freedom of Information
Act
896 Arbitration
899 Administrative Procedure
Act/Review or Appeal of
Agency Decision
950 Constitutionality of
State Statutes

IMMIGRATION
462 Naturalization Application
465 Other Immigration
Actions

V. ORIGIN (Place an X in One Box Only)


1 Original
Proceeding

2 Removed from
State Court

Remanded from
Appellate Court

4 Reinstated or
Reopened

5 Transferred from
Another District
(specify)

6 Multidistrict
Litigation

Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):

42 USC 1983

VI. CAUSE OF ACTION Brief description of cause:


Police misconduct

CHECK IF THIS IS A CLASS ACTION


VII. REQUESTED IN
UNDER RULE 23, F.R.Cv.P.
COMPLAINT:
VIII. RELATED CASE(S)
(See instructions):
IF ANY
JUDGE
DATE

CHECK YES only if demanded in complaint:


Yes
No
JURY DEMAND:

DEMAND $

DOCKET NUMBER

SIGNATURE OF ATTORNEY OF RECORD

/s/

09/11/2015
FOR OFFICE USE ONLY
RECEIPT #

AMOUNT

APPLYING IFP

JUDGE

MAG. JUDGE

Case 1:15-cv-05267 Document 1-1 Filed 09/11/15 Page 2 of 2 PageID #: 13


CERTIFICATION OF ARBITRATION ELIGIBILITY

Local Arbitration Rule 83.10 provides that with certain exceptions, actions seeking money damages only in an amount not in excess of $150,000,
exclusive of interest and costs, are eligible for compulsory arbitration. The amount of damages is presumed to be below the threshold amount unless a
certification to the contrary is filed.
Richard Cardinale
plaintiff
I, ______________________,
counsel for __________________,
do hereby certify that the above captioned civil action is
ineligible for compulsory arbitration for the following reason(s):

monetary damages sought are in excess of $150,000, exclusive of interest and costs,
the complaint seeks injunctive relief,
the matter is otherwise ineligible for the following reason

Case alleges a violation of the

Constitution

DISCLOSURE STATEMENT - FEDERAL RULES CIVIL PROCEDURE 7.1

Identify any parent corporation and any publicly held corporation that owns 10% or more or its stocks:

N/A
RELATED CASE STATEMENT (Section VIII on the Front of this Form)
Please list all cases that are arguably related pursuant to Division of Business Rule 50.3.1 in Section VIII on the front of this form. Rule 50.3.1 (a)
provides that A civil case is related to another civil case for purposes of this guideline when, because of the similarity of facts and legal issues or
because the cases arise from the same transactions or events, a substantial saving of judicial resources is likely to result from assigning both cases to the
same judge and magistrate judge. Rule 50.3.1 (b) provides that A civil case shall not be deemed related to another civil case merely because the civil
case: (A) involves identical legal issues, or (B) involves the same parties. Rule 50.3.1 (c) further provides that Presumptively, and subject to the power
of a judge to determine otherwise pursuant to paragraph (d), civil cases shall not be deemed to be related unless both cases are still pending before the
court.

NY-E DIVISION OF BUSINESS RULE 50.1(d)(2)


1.)

Is the civil action being filed in the Eastern District removed from a New York State Court located in Nassau or Suffolk
No
County:_________________________

2.)

If you answered no above:


a) Did the events or omissions giving rise to the claim or claims, or a substantial part thereof, occur in Nassau or Suffolk
No
County?_________________________
b) Did the events of omissions giving rise to the claim or claims, or a substantial part thereof, occur in the Eastern
Yes
District?_________________________

If your answer to question 2 (b) is No, does the defendant (or a majority of the defendants, if there is more than one) reside in Nassau or
Suffolk County, or, in an interpleader action, does the claimant (or a majority of the claimants, if there is more than one) reside in Nassau
or Suffolk County?______________________
(Note: A corporation shall be considered a resident of the County in which it has the most significant contacts).
BAR ADMISSION
I am currently admitted in the Eastern District of New York and currently a member in good standing of the bar of this court.
Yes
No
Are you currently the subject of any disciplinary action (s) in this or any other state or federal court?
Yes
(If yes, please explain)
No

I certify the accuracy of all information provided above.

/s/
Signature:____________________________________________

Case 1:15-cv-05267 Document 1-2 Filed 09/11/15 Page 1 of 2 PageID #: 14


AO 440 (Rev. 12/09) Summons in a Civil Action

UNITED STATES DISTRICT COURT


for the

Eastern District
ofof
New
York
__________
District
__________
Roger Arthur
Plaintiff

v.
City of New York, P.O. Anthony Denatale, P.O.
Steven Cosentino, Detective Michael Burke, et al.,
Defendant

)
)
)
)
)
)
)

Civil Action No.

SUMMONS IN A CIVIL ACTION


To: (Defendants name and address) City of New York, 100 Church St., NY, NY 10007
P.O. Anthony Denatale (tax # 952282), 121 Precinct, 970 Richmond Ave., Staten
Island, NY 10314
P.O. Steven Cosentino (tax # 948816 ), 121 Precinct, 970 Richmond Ave., Staten
Island, NY 10314
Detective Michael Burke (tax # 929800), 121 Precinct, 970 Richmond Ave.,
Staten Island, NY 10314

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: Richard Cardinale
Attorney at Law
26 Court Street, suite 1815
Brooklyn, NY 11242
718-624-9391

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 1:15-cv-05267 Document 1-2 Filed 09/11/15 Page 2 of 2 PageID #: 15


AO 440 (Rev. 12/09) 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 $

0.00

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:

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