Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 1 of 16

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF COLORADO

Civil Action No. ____________________

SAMONE WALKER, and

DASHAWN WALKER,
Plaintiffs,
v.
CITY AND COUNTY OF DENVER, DENVER SHERIFF DEPARTMENT, a Municipal
Corporation,
Defendant.

COMPLAINT AND JURY DEMAND

Plaintiffs Samone Walker and DaShawn Walker, by and through their counsel, Wilbur C.
Smith of WILBUR C. SMITH, P.C. and Martha H. Eskesen of MARTHA H. ESKESEN, P.C.,
respectfully allege for their Complaint and Jury Demand as follows:
I. INTRODUCTION & NATURE OF THE CLAIM
1.

Samone Walker and DaShawn Walker are female deputy sheriffs employed by the

Defendant. They allege that the City and County of Denver, through the Denver Sheriff
Department, discriminates against female deputy sheriffs through policies and practices as set
forth below.
II. JURISDICTION AND VENUE
2.

This Court has jurisdiction of this action under 42 U.S.C. 2000e-5(f)(3), 28 U.S.C.

1331, 1343(a)(3) and 1343(a)(4). The facts alleged herein occurred within the District of
Colorado.

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 2 of 16

III. ADMINISTRATIVE PREREQUISITES

3.

Plaintiffs Samone Walker and DaShawn Walker each timely filed Charges of

Discrimination with the United States Equal Employment Opportunity Commission (EEOC) and
the EEOC issued each a Notice of Right to Sue on August 27, 2015. Thus, this action is timely
filed.
IV. PARTIES
4.

Plaintiffs Samone Walker and DaShawn Walker are female deputy sheriffs. DaShawn

Walker currently supervises and guards prisoners in the Denver County Jail. Samone Walker
supervised and guarded prisoners at the Denver County Jail until approximately January 2015,
when she was injured subduing a combative prisoner. At present, Samone Walker is not
supervising and guarding prisoners because she is temporarily on modified duty as a result of her
injury. She anticipates being returned to supervising and guarding prisoners once she has
recovered from her injury. As female deputies, Samone Walker and DaShawn Walker are at all
times subject to reassignment to any position within a deputys job description, and they are in a
position to know of discrimination perpetrated against other female deputies. Thus in those
instances, if any, where Samone Walker and DaShawn Walker may not be personally victimized
by the acts of discrimination alleged herein, they are likely to be victimized in the future, and as
members of the same protected class, they are impacted, and thus aggrieved by the
discriminatory acts.
5.

The Defendant, City and County of Denver, controls and operates the Denver Sheriff

Department (Department). The City and County of Denver is a municipal corporation within the
State of Colorado and exists by virtue of the laws, constitution and statutes of Colorado. At all

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 3 of 16

times relevant to the allegations in this complaint, Defendant is and was a person as defined by
42 U.S.C. 2000e(a) and an employer as defined by 42 U.S.C. 2000e(b).
V. FACTUAL ALLEGATIONS
Overview
6.

The Department operates two jail divisions in separate geographical locations, the Denver

County Jail Division (COJL), and the Downtown Detention Center Division (DDC).
7.

The COJL is located at 10500 E. Smith Road Denver, Colorado, 80239. Most of

Denvers female prisoners are detained in Building 21 of the COJL. Male prisoners including
work release, alternative sentencing, central kitchen, and bakery workers are also housed at the
COJL.
8.

The DDC is located at 490 W. Colfax Avenue, Denver, Colorado, 80204. A smaller

number of Denvers female prisoners are detained at the DDC along with a greater number of
male prisoners. Additional operations at the DDC include an intake center, central property,
arraignment courts, central laundry, and infirmary.
9.

Prisoners at both DDC and COJL are housed in units (pods) that are separate and discrete

from one another. For example, prisoners in male pods are separated and have no access to
prisoners in female pods.
Work Assignments and Gender Distribution
10.

Plaintiffs are responsible for the supervision and guarding of prisoners, which includes

providing for the security, care, custody and safety of prisoners and the public.
11.

Prisoner supervision and guarding entails multiple hazards, stressors, and hardships

including, but not limited to, physically subduing violent prisoners, varying shift schedules,

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 4 of 16

significant overtime, exposure to infectious diseases, exposure to prisoners emotional and angry
outbursts, and exposure to life-threatening violence.
12.

Approximately 25 % of all Denver Deputies are female. Approximately 22% of all

Denver prisoners are female.

Cross-Gender Supervision
13.

Cross-gender supervision, where a deputy must supervise and guard prisoners of the

opposite sex often requires greater vigilance and results in greater job stress than when
supervising and guarding prisoners of the same sex. Cross-gender supervision is more
challenging for both male and female deputies. In cross-gender supervision, deputies of either
gender must be extra vigilant to avoid unreasonable intrusions of a prisoners privacy. In crossgender supervision, deputies, both male and female, are more vulnerable to false allegations of
abuse resulting in internal investigations which are stressful, embarrassing, and time consuming
even if a deputy is exonerated. In the Denver Jails cross-gender supervision is even more
difficult for female deputies because the Department fails to take reasonable measures to prevent
male inmates from sexually harassing female deputies.
14.

Despite the hardships of cross-gender supervision, the lawful and reasonable response is

not to abolish cross-gender supervision, but to distribute the burden equally and proportionately
to deputies of both genders. The Department rarely assigns cross-gender duties to male deputies
but routinely assigns cross-gender duties to female deputies.
15.

The Department maintains a policy and practice of, whenever possible, assigning only

female deputies to the supervision of female pods, and not including male deputies in the
responsibility of cross-gender supervision. At the same time, the Department does assign female
deputies to cross-gender responsibilities in male pods, but under circumstances that

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 5 of 16

unreasonably, and unnecessarily, subject female deputies to sexual harassment from the male
prisoners. Moreover, female deputies are required to conduct cross-gender pat searches while
male deputies are not.
16.

The Departments policies and practices of concentrating female deputies into female

pods has the result of limiting, segregating, and classifying female deputy sheriffs and deprives
female deputies of employment opportunities, and adversely affects their status as employees,
because of their sex. The Departments assignment policy, together with the sexual harassment
by male prisoners, restricts female deputies to working in female pods.
17.

On very rare occasions, when there are no female deputies available, the Department will

temporarily assign a male deputy to work in a female pod. When this occurs the male deputies
are not held to the same duty requirements as are female deputies. Cross-gender supervision
duties should be distributed equally and proportionately to both male and female deputies. Both
genders possess a wealth of skill, experience, and training that should be available to benefit all
deputies and all prisoners regardless of gender.
18.

Consequently, because of the Departments unequal cross-gender policy and practice,

female deputies bear an unequal burden of cross-gender supervision. Female deputies are
concentrated into assignments that involve guarding only female prisoners. Female deputies are
adversely impacted by the Departments unequal policy and practice in one or more of the
following ways:
a.
19.

Female deputies are denied diversification in their work assignments.

The Departments hiring practices restrict the number of female deputies to being almost

at parity with the number of female prisoners. Approximately 25% (or less) of the deputies are
female while approximately 22% of the prisoners are female. This, together with the policy that

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 6 of 16

only female deputies guard female inmates, creates an unreasonable staffing shortage within
overcrowded female pods. The staffing shortage is exacerbated because female deputies, unlike
male deputies, must also provide cross-gender supervision.
20.

The Department has hired only enough female deputies to minimally cover supervision

demands in the female prisoner pods. Thus, without relief or support from male deputies, most
female deputies find themselves restricted to prisoner-contact-assignments, most often in the
female pods, and are denied the benefit of diversity in work experience. Rotation into more
diversified assignments is needed both as a reprieve from the hardships of direct prisoner
contact, and also to gain the benefits of wider experience. Such assignments include, but are not
limited to, corridor assignments, main gate assignments, security officer assignments, and
emergency response assignments. Female deputies do not get an equal share of these preferable
assignments.
b.
21.

Female deputies are exposed to greater danger and hardships.

Denvers primary female pod, Building 21 at the COJL, is overcrowded, inadequately

staffed, and is unreasonably hazardous to deputies and prisoners alike. Female prisoners with
behavioral issues, violence issues, and mental health issues are mixed in with the general
population. Violent prisoners are mixed with non-violent prisoners. The behaviorally defiant
are mixed with the behaviorally compliant. These conditions increase the hardships upon female
deputies who must protect both themselves and the prisoners under their charge.
22.

Female prisoners, unlike male prisoners, are not carefully searched before they are sent to

the female pod. This causes greater risk for female deputies assigned to Building 21, the female
pod at COJL.

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 7 of 16

23.

In the Denver jails female prisoners file a greater number of grievances against deputies,

require more work from deputies, cause more injuries to deputies, and require more vigilance
from deputies.
c.
24.

Female deputies have fewer opportunities than male deputies.

By concentrating female deputies in Building 21, the primary female pod, female

deputies are denied the diversity and variety of experience that is available to male deputies.
Because male deputies enjoy more diversity in job assignments, they have an advantage in
experience, contacts, and activities that lead promotions, beneficial assignments, and prestigious
assignments. Moreover, male deputies have more opportunities to get reprieve from the stressors
and tensions of prisoner supervision.
d.
25.

Female deputies suffer greater job stress and burnout.

The continual supervision of female prisoners, without a break, is exhausting and

demoralizing, resulting in greater stress and burnout. Challenges inherent to supervising female
prisoners include pregnancy, separation from children, domestic abuse victimization, sexual
abuse victimization, and other special needs. This stress is exacerbated at the Denver jails
because the Department does not provide the same level of support to the female pods as it does
the male pods.
Sexual Harassment from Male Prisoners
26.

Absent reasonable measures being enforced by a Sheriffs Department, male prisoners

will severely and/or persistently inflict sexual harassment upon female deputies, and other
female employees.
27.

During all times relevant to this Complaint, female deputies have been, and continue to

be, called cunts, whores, bitches, sluts, and other sexually derogatory obscenities. Prisoners

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 8 of 16

openly and persistently talk about performing sex acts on female deputies and talk about sexually
assaulting female deputies. Prisoners make demeaning comments about female deputies bodies.
Prisoners continue to harass female deputies with obscene and derogatory sounds, calls, and
gestures.
28.

During cross-gender pat searches, which only female deputies are required to do,

prisoners routinely and persistently sexually harass the female deputies.

29.

Prisoners intentionally masturbate in front of female deputies and intentionally expose

their genitals to female deputies.

30.

Female deputies are discouraged from reporting the sexual abuse and harassment by

prisoners. Often harassment and abuse goes unreported because the Department does not take
reasonable measures against the abuse even when it is reported.
31.

Corrective measures that would minimize and mitigate the sexual harassment of female

deputies by male prisoners could and should be implemented. These measures include, but are
not limited to, staff training, the adoption of a zero tolerance policy, the adoption of a effective
policy for reporting prisoner inflicted abuse, the revocation of privileges from offenders, the
isolation of offenders, the prompt rebuke of offenders, the referral of offenders for criminal
charges, and an increase in internal penalties for offenders. Notwithstanding the availability of
reasonable corrective measures the Department has failed to respond with reasonable
preventative measures.
32. The sexual abuse by male prisoners is unwanted by the Plaintiffs and substantially and
negatively alters the conditions of their employment. Moreover, the well-known existence of
sexual abuse discourages the Plaintiffs from pursuing work assignments in male pods.

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 9 of 16

VI. STATEMENT OF CLAIMS

FIRST CLAIM FOR RELIEF
Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000e, et seq.
[Discrimination through Disparate TreatmentCross-Gender and Work Conditions]
33.

Plaintiffs incorporate the allegations in the foregoing and subsequent paragraphs.

34.

The Department has intentionally maintained, and continues to maintain through policy

and practice, conditions whereby the burden of cross-gender supervision is unequally imposed
upon female deputies.
35.

The Department has failed provide to female deputies with the same support and

opportunities that it provides to male deputies.

36.

Female deputies are required to provide cross-gender supervision while male deputies are

not.
37.

Female deputies are required to pat-search both male and female prisoners, while male

deputies only pat-search male prisoners.

38.

This intentional disparate treatment results in male deputies being treated more favorably

than female deputies, and it causes adverse consequences to female deputies, because of their
gender, in one or more of the following ways:
(a) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to conditions in the female pods;
(b) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to the lack of adequate staffing;
(c) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to deprivation of adequate equipment and facilities necessary to maintain a safe
environment;

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 10 of 16

(d) Exposure to increased risk of physical harm greater than that experienced by male
deputies, by failing to segregate, and appropriately assign, violent and emotionally unstable
prisoners;
(e) Exposure to increased risk of physical harm greater than the level of exposure
experienced by male deputies because of more frequent fights in the female pods;
(f) Being forced to work harder, under more difficult circumstances, than male deputies;
(g) Limitations on experience in job duties, and being stereotyped by holding a femaleonly assignment, which limits the ability to compete for assignments and advancements when
compared to male deputies;
(h) Being subjected to more complaints and grievances than are experienced by male
deputies due to the propensity of female prisoners to file grievances and complaints at a greater
rate than male prisoners;
(i) Being subjected to increased levels of job stress, job burnout, and emotional harm
when compared to male deputies.
SECOND CLAIM FOR RELIEF
Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000e, et seq.
[Discrimination through Disparate ImpactCross-Gender and Work Conditions]
39.

Plaintiffs incorporate the allegations in the foregoing and subsequent paragraphs.

40.

The Department has maintained, and continues to maintain through policy and practice,

conditions whereby cross-gender supervision is disproportionally imposed upon female deputies.

41.

The Department has maintained, and continues to maintain through policy and practice

conditions that fail to provide female deputies with the same support, equipment, supplies,
protection, staffing, and facilities that it provides to male deputies.

10

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 11 of 16

42.

Female deputies are responsible for essentially all supervision of female prisonersand

partial supervision of male prisoners.

43.

This policy and practice has a disparate impact upon females, a protected class to which

Plaintiffs belong.
44.

The disparate impact includes less favorable treatment in the terms and conditions of

employment and adverse consequences in one or more of the following ways:

(a) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to conditions in the female pods;
(b) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to the lack of adequate staffing;
(c) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to deprivation of adequate equipment and facilities necessary to maintain a safe
environment;
(d) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, by failing to segregate and appropriately assign, violent and emotionally unstable
prisoners;
(e) Exposure to increased risk of physical harm that is greater than that experienced by
male deputies because of more frequent fights in the female pods;
(f) Being forced to work harder, under more difficult circumstances, than male deputies;
(g) Limitations on experience in job duties, and being stereotyped by holding a femaleonly assignment, which limits the ability to compete for assignments and advancements when
compared to male deputies;

11

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 12 of 16

(h) Being subjected to more complaints and grievances than are experienced by male
deputies due to the propensity of female prisoners to file grievances and complaints at a greater
rate than male prisoners;
(i) Being subjected to increased levels of job stress, job burnout, and emotional harm
when compared to male deputies.
THIRD CLAIM FOR RELIEF
Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000e2(a)(2), et seq.
[Intentional Discrimination through Limitation, Segregation, and
Classification of Employees]
45.

Plaintiffs incorporate the allegations in the foregoing and subsequent paragraphs.

46.

The Department has intentionally maintained, and continues to maintain through policy

and practice, the concentration of female deputies into assignments supervising female prisoners,
which results in the segregation of female deputies into female prisoner units. The policy and
practice further limits female deputies from other assignments. This policy and practice is based
on sex.
47.

This limitation, segregation, and classification of female deputies causes adverse

consequences to female deputies, because of their gender, including:

(a) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to conditions in the female pods;
(b) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to the lack of adequate staffing;
(c) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, due to deprivation of adequate equipment and facilities necessary to maintain a safe
environment;

12

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 13 of 16

(d) Exposure to increased risk of physical harm, greater than that experienced by male
deputies, by failing to segregate, and appropriately assign, violent and emotionally unstable
prisoners;
(e) Exposure to increased risk of physical harm that is greater than that experienced by
male deputies because of more frequent fights in the female pods;
(f) Being forced to work harder, under more difficult circumstances, than male deputies;
(g) Limitations on experience in job duties, and being stereotyped by holding a femaleonly assignment, which limits the ability to compete for assignments and advancements when
compared to male deputies;
(h) Being subjected to more complaints and grievances than are experienced by male
deputies due to the propensity of female prisoners to file grievances and complaints at a greater
rate than male prisoners;
(i) Being subjected to increased levels of job stress, job burnout, and emotional harm
when compared to male deputies.
FOURTH CLAIM FOR RELIEF
Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000e, et seq.
[Suit for Injunctive and Declaratory Relief, Discrimination through
Sexual Harassment and Hostile Work Environment]
48.

Plaintiffs incorporate the allegations in the foregoing and subsequent paragraphs.

49.

When female deputies are assigned to supervise male prisoners they are subjected to

unwanted sexual harassment from prisoners.

50.

Some female deputies are assigned only temporarily to supervise males either at the

COJL or DDC, while other female deputies have long-term assignments in male prisoner pods.
Female deputies are severely and/or persistently subjected to sexual harassment in long- term
and short-term assignments.
13

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 14 of 16

51.

Plaintiffs are not presently assigned to long-term supervision of male prisoners; however,

they have been temporarily assigned to supervise male prisoners during times relevant to this
Complaint. When they have been assigned to supervise males they have experienced sexual
harassment from prisoners. Plaintiffs are always subject to reassignment into a male pod, and
therefore they are likely to suffer future injury from sexual harassment by male prisoners, and
future sexual harassment from prisoners poses a real and immediate threat. As members of the
protected class that is being victimized, they are humiliated, emotionally distressed, and thus
aggrieved, by the ongoing sexual harassment and hostile work environment that is ongoing.
52.

The abuse is directed at the Plaintiffs because they are female. Male deputies are not

exposed to comparable abuse.

53.

The overall context of this abuse is severe and/or pervasive. When supervising and

guarding male prisoners, a female deputy is often assigned as the lone deputy in a pod where she
is surrounded and outnumbered male prisoners. Sexual remarks are often tinged with threats of
violence.
54.

The language used against female deputies is vile, damaging, and degrading by any

objective standard. This is especially so when uttered in a confined space where there is an ever
present threat of serious, even lethal, physical harm. At the DDC, both male and female deputies
are often locked alone in a pod with thirty to sixty male prisoners.
55.

The sexual abuse significantly and negatively alters the conditions of employment for

Plaintiffs and all female deputies by causing fear, emotional distress, and a fear of being assigned
to male pods. It also degrades and diminishes the stature of female deputy sheriffs.
56.

Given the close confines of the jail, the reports that have been filed, and the general

knowledge of predictable prisoner behavior, the Department either knows, or with reasonable

14

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 15 of 16

diligence should know, of the sexually abusive environment that pervades the Denver City and
County jails.
57.

There are means and measures by which the Department could contain, control, and

minimize this sexually abusive environment. Despite knowledge of the conditions, and the
availability of preventative measures, the Department has failed to implement reasonable
measures that would protect its female employees from this damaging and abusive environment.

VII.

PRAYER FOR RELIEF

WHEREFORE, Plaintiffs respectfully request that this court enter judgment in their
favor and against Defendant, and award them all relief as allowed by law, including, but not
limited to the following:
As to Claims One through Three:
(a) Declaratory and injunctive relief;
(b) Economic damages;
(c) Compensatory damages, including, but not limited to, emotional pain,
suffering, inconvenience, mental anguish, loss of enjoyment of life, and other
non-pecuniary losses;
(d) Pre-judgment and post-judgment interest;
(e) Attorneys fees and costs; and
(f) Such further relief as justice may require.
As to Claim Four:
(a) Declaratory and injunctive relief;
(b) Attorneys fees and costs; and
(c) Such further relief as justice may require.
15

Case 1:15-cv-02539-MSK Document 1 Filed 11/18/15 USDC Colorado Page 16 of 16

PLAINTIFFS DEMAND A JURY TRIAL ON ALL ISSUES SO TRIABLE.

Dated this 18th day of November, 2015

WILBUR C. SMITH, P.C.

s/ Wilbur C. Smith
Wilbur C. Smith, P.C
5353 Manhattan Circle
Suite 202
Boulder, CO 80303
Telephone: (303) 996-4200
E-mail: wil@civilcriminal.com

MARTHA H. ESKESEN, P.C.

s/Martha H. Eskesen
5445 DTC Parkway, Penthouse 4
Greenwood Village, CO 80111
Telephone: (303) 486-6938
Facsimile: (303) 573-4921
E-mail: meskesen@eskesenlaw.com
Attorneys for Plaintiffs

16

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Case 1:15-cv-02539-MSK Document 1-2 Filed 11/18/15 USDC Colorado Page 1 of 2

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

UNITED STATES DISTRICT COURT

for the

District
of Colorado
__________
District
of __________
Samone Walker, and
DaShawn Walker,
Plaintiff

v.
City and County of Denver, Denver Sheriff
Department, a Municipal Corporation,
Defendant

)
)
)
)
)
)
)

Civil Action No.

SUMMONS IN A CIVIL ACTION

To: (Defendants name and address) City and County of Denver, Denver Sheriff Department, a Municipal Corporation
PO Box 1108
Denver, CO 80201

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: Wilbur C. Smith, Wilbur C. Smith, P.C.,
5353 Manhattan Circle, Suite 202, Boulder, CO 80303
Martha H. Eskesen, Martha H. Eskesen, P.C.,
5445 DTC Parkway, Penthouse 4, Greenwood Village, CO 80111

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:

11/18/2015
Signature of Clerk or Deputy Clerk

Case 1:15-cv-02539-MSK Document 1-2 Filed 11/18/15 USDC Colorado Page 2 of 2

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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