AO 83 (Rev. 06/09) Summons in a Criminal Case

UNITED STATES DISTRICT COURT

for the

__________ District of __________

United States of America )

v.

)

)

)

Case No.

Defendant

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)

)

SUMMONS IN A CRIMINAL CASE

YOU ARE SUMMONED to appear before the United States district court at the time, date, and place set forth below to answer to one or more offenses or violations based on the following document filed with the court:

’ Indictment ’ Superseding Indictment ’ Information ’ Superseding Information ’ Complaint ’ Probation Violation Petition ’ Supervised Release Violation Petition ’ Violation Notice ’ Order of Court

Place:	Courtroom No.:
	Date and Time:

This offense is briefly described as follows:

Date:

Issuing officer’s signature

Printed name and title

I declare under penalty of perjury that I have:

’ Executed and returned this summons ’ Returned this summons unexecuted

Date:

Server’s signature

Printed name and title

AO 83 (Rev. 06/09) Summons in a Criminal Case (Page 2)

Case No.

This second page contains personal identifiers and therefore should  

not be filed in court with the summons unless under seal.

(Not for Public Disclosure)

INFORMATION FOR SERVICE

Name of defendant/offender:

Last known residence:

Usual place of abode (if different from residence address):

If the defendant is an organization, name(s) and address(es) of officer(s) or agent(s) legally authorized to receive service of process:

If the defendant is an organization, last known address within the district or principal place of business elsewhere in the  United States:

PROOF OF SERVICE

This summons was received by me on (date) .

’ I personally served the summons on this defendant at (place) on (date) ; or

’ On (date) 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, and I mailed a copy to the individual’s last known address; or

’ I delivered a copy of the summons to (name of individual) , who is authorized to receive service of process on behalf of (name of organization)

on (date) and I mailed a copy to  

the organizations’s last known address within the district or to its principal place of business elsewhere in the United States; or

’ The summons was returned unexecuted because:

.

I declare under penalty of perjury that this information is true.

Date returned:

Server’s signature

Printed name and title

Remarks: