Sheriff lawsuit

Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 1 of 10

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO Civil Action No. CLAUDIA A. MERCADO, GLORIA Y. MERCADO, JAMES MERCADO & JOE ANTHONY MERCADO, surviving heirs of JOSE MERCADO-NOVA deceased; and THE ESTATE OF JOSE MERCADO-NOVA, Claudia A. Mercado Personal Representative, Plaintiffs, vs.

BOARD OF COMMISSIONERS, COUNTY OF WELD, STATE OF COLORADO; WELD COUNTY SHERIFF’S DEPARTMENT; and WELD COUNTY DEPUTY SHERIFF TIMOTHY J. BOXLEY, individually.

Defendants, ______________________________________________________________________________

COMPLAINT FOR DAMAGES AND JURY DEMAND __________________________________________________________________ COMES NOW the Plaintiffs, by and through their attorneys, Steven B. Ray and DezaRae LaCrue and Patricia Meester, and for their Complaint against the above named Defendants, state and allege as follows: I. JURISDICTION AND VENUE

1.

This action arises under the Constitution and laws of the United States and the

State of Colorado, and is brought pursuant to 42 U.S.C. § 1983, C.R.S. § 13-21-202 and the common law of the State of Colorado.

2.

Plaintiffs have satisfied the jurisdictional prerequisites of the Colorado

Governmental Immunity Act, C.R.S. § 24-10-109, by timely submitting a Notice of Claim.

Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 2 of 10

3.

Jurisdiction in this Court is appropriate pursuant to 42 U.S.C. § 1983.

4.

Venue is proper pursuant to 28 U.S.C. § 1391 (b). All acts or omissions of the

Defendants, causing the injuries herein alleged, occurred within the State and District of Colorado.

II. GENERAL AND FACTUAL ALLEGATIONS

5.

On or about 17 November 2015, Jose Mercado-Nova was severely injured

because of a motor vehicle collision with a Weld County motor vehicle, a Ford Explorer Police Interceptor, operated by Weld County Sheriff Deputy Timothy J. Boxley.

6.

Jose Mercado-Nova died in the early morning of 18 November 2015 as a result of

the injuries he received in a motor vehicle collision.

7.

Jose Mercado-Nova, deceased, died without a surviving spouse.

8.

Plaintiffs Claudia A. Mercado, Gloria Y. Mercado, James Mercado and Joe

Anthony Mercado have standing to bring this lawsuit as they are surviving heirs of Jose Mercado-Nova, deceased.

9.

Plaintiffs have, at all times material to the allegations of this Complaint, been

residents of the County of Weld, State of Colorado. All are citizens of the United States.

10.

At all times material to the allegations of the Complaint, Defendant Weld County

was and is currently a county governmental entity with its principal place of business at 1150 ‘O’ Street, Greeley, Colorado.

11.

At all times material to the allegations of the Complaint, Timothy J. Boxley was a

resident of the State of Colorado.

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Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 3 of 10

12.

The motor vehicle collision occurred on or about 3:39 pm at the intersection of

US Highway 85 and Weld County Road 66, north of Greeley.

13.

The weather and road conditions were clear and dry at the time and place of the

collision.

14.

Immediately prior to the collision, deceased Jose Mercado-Nova was stopped at

the east side of US Highway 85, westbound on Weld County Road 66. He was on his way to pick up a grandchild at New Hope School west of US Highway 85 on Weld County Road 66.

15.

Immediately prior to the collision, Defendant Timothy J. Boxley was northbound

on US Highway 85 driving the Weld County vehicle.

16.

On the date, time and place of the collision, Defendant Timothy J. Boxley was

acting within the course and scope of his employment as a deputy sheriff in the Weld County Sheriff’s Office.

17.

Defendant Timothy J. Boxley was driving the county vehicle north on US

Highway 85 towards the collision at speeds in excess of the posted speed limit up to and including a speed of 101 miles per hour shortly before the collision according to the investigation and report of the Colorado State Patrol.

18.

Emergency lights and siren were not being used by Deputy Boxley as he sped

northbound on US Highway 85 although the Weld County vehicle was equipped with such equipment.

19.

On information and belief, Jose Mercado-Nova, deceased, believed that the motor

vehicle northbound on US Highway 85 driven by Defendant Timothy J. Boxley was traveling within the lawful speed limit of 65 mph as did other witnesses of the collision.

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Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 4 of 10

20.

When Jose Mercado-Nova attempted to drive west, across the northbound lanes of

US Highway 85, he was struck by the Weld County Ford Explorer Police Interceptor estimated to still be travelling at a speed of 88 mph, causing a violent impact and life-threatening injuries to Jose Mercado-Nova.

21.

Jose Mercado-Nova was taken by ambulance to North Colorado Medical Center

in Greeley where he died in the early morning hours of 18 November 2015 due to his injuries.

22.

As a consequence of the acts and omissions of Deputy Timothy J. Boxley and

Defendant Weld County through its employee and agent Timothy J. Boxley, Plaintiffs Claudia A. Mercado, Gloria Y. Mercado, James Mercado and Joe Anthony Mercado have suffered emotional injuries, grief and anguish, loss of comfort and society of their father, and have incurred economic damages for which they are entitled to compensation.

23.

As a consequence of the acts and omissions of Deputy Timothy J. Boxley and

Defendant Weld County through its employee and agent Timothy J. Boxley, the Estate of Jose Mercado-Nova has suffered pecuniary loss including funeral expenses, and hospital and medical expenses in an amount exceeding $70,000.00 before death.

III. FIRST CLAIM FOR RELIEF (RESPONDEAT SUPERIOR - Weld County and Weld County Sheriff)

24.

Plaintiff incorporates the allegations of paragraphs 1 through 23 as if fully set

forth herein.

25.

Defendants Board of Commissioners, County of Weld, State of Colorado and

4

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Weld County Sheriff’s Department are vicariously liable under the doctrine of Respondeat Superior for the above-described acts of their employee Timothy J. Boxley who at all times pertinent to the events described in this Complaint was acting within the authority, scope and course of his employment.

26.

The acts and/or omissions of Timothy J. Boxley caused injuries, damages and

losses to Plaintiffs as more fully described above.

IV. SECOND CLAIM FOR RELIEF (Negligence and Negligence per se Resulting in Wrongful Death – TIMOTHY J. BOXLEY ) (C.R.S. §13-21-202 through 204)

27.

Plaintiff incorporates the allegations of paragraphs 1 through 26 as if fully set

forth herein.

28.

At the time and place of the collision, Deputy Timothy J. Boxley was required to

obey the lawfully posted speed limit of 65 miles per hour on northbound US Highway 85 when driving the Weld County Ford Explorer Police Interceptor.

29.

Defendant Timothy J. Boxley on 17 November 2015 owed a duty to Jose

Mercado-Nova and to the public in general to exercise reasonable care in the operation of the Weld County motor vehicle on US Highway 85 in Weld County, Colorado.

30.

Defendant Timothy J. Boxley on 17 November 2015 owed a duty to Jose

Mercado-Nova and to the public in general to follow law enforcement policies, rules and regulations for exceeding posted speed limit on US Highway 85 in the operation of the Weld County motor vehicle.

5

Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 6 of 10

31.

Deputy Timothy J. Boxley failed to exercise reasonable care when he drove the

Weld County Ford Explorer on US Highway 85 and into the vehicle driven by Jose MercadoNova, thereby breaching the above duties he owed to Jose Mercado-Nova, and was negligent.

32.

Deputy Timothy J. Boxley’s conduct in operating the Weld County Ford Explorer

on US Highway 85 was in violation of applicable traffic statutes of the State of Colorado and Weld County as well as law enforcement policies, rules and regulations for exceeding posted speed limits in bone fide emergencies, so that his conduct constitutes negligence per se.

33.

The statutes and law enforcement policies, rules and regulations violated by

Deputy Timothy J. Boxley were enacted and designed to prevent the harm that Deputy Boxley’s conduct caused.

34.

Jose Mercado-Nova, deceased, was a member of the class of people that the

statutes, policies, rules and regulations were designed to protect.

35.

Defendant Deputy Timothy J. Boxley’s actions at and near the time of the

collision were willful and wanton; were done with reckless disregard for the welfare and safety of Jose Mercado-Nova; and constitute extreme and outrageous conduct.

36.

Defendant Deputy Timothy J. Boxley’s actions causing the death of Jose

Mercado-Nova constitute a felonious killing as that term is used in the Wrongful Death Act C.R.S. §13-21-203 and C.R.S. §15-11-803.

37.

As a direct and proximate cause of the actions and conduct of Defendant Timothy

J. Boxley including his negligence, negligence per se, Plaintiffs as adult children of Jose Mercado-Nova have sustained damages including, but not limited to mental anguish, grief, loss of society and companionship of their father, as well as economic damages.

6

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V. THIRD CLAIM FOR RELIEF (Survival Action – C.R.S. §13- 20-101 – ALL DEFENDANTS)

38.

Plaintiff incorporates the allegations of paragraphs 1 through 37 as if fully set

forth herein.

39.

As a direct and proximate cause of the actions and conduct of Defendant Timothy

J. Boxley, Plaintiff Estate of Jose Mercado-Nova has sustained economic damages including, but not limited to funeral, hospital and medical expenses.

VI. FOURTH CLAIM FOR RELIEF (Outrageous Willful, Wanton, and Reckless Conduct – ALL DEFENDANTS)

40.

Plaintiff incorporates the allegations of paragraphs 1 through 39 as if fully set

forth herein.

41.

Defendant Deputy Timothy J. Boxley’s actions at and near the time of the

collision were willful and wanton; were done with reckless disregard for the welfare and safety of Jose Mercado-Nova; and, constitute extreme and outrageous conduct.

42.

As a direct and proximate cause of the actions and conduct of Defendant Timothy

J. Boxley including his willful, wanton, reckless and outrageous conduct, the adult children of Jose Mercado-Nova and the Estate of Jose Mercado-Nova have sustained damages including, but not limited to mental anguish, grief, loss of society and companionship of their father, as well as economic damages.

7

Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 8 of 10

VI. FIFTH CLAIM FOR RELIEF (42 U.S.C. § 1983 - Violation of Jose Mercado-Nova’s Constitutional Civil Rights Resulting in Death – ALL DEFENDANTS)

43.

Plaintiff incorporates the allegations of paragraphs 1 through 42 as if fully set

forth herein.

44.

At all times material to this complaint, Defendant Deputy Timothy J. Boxley

acted under color of law, statutes, ordinances, customs, and usage of the County of Weld, State of Colorado, and the Weld County Sheriff’s Department.

45.

Defendant Deputy Timothy J. Boxley, by his actions, disregarded Jose Mercado-

Nova’s physical safety and security.

46.

Defendant Deputy Timothy J. Boxley’s conduct leading up to this crash was an

abuse and misuse of power and position, objectively unreasonable, and done with reckless intent shocking the conscious.

47.

At all times material to this complaint, Jose Mercado-Nova had a substantive due

process right, secured by the U.S. Constitution, not to be deprived of life, liberty or property without due process of law.

48.

Jose Mercado-Nova’s constitutional right to life was well-established law at the

time of this collision and death.

49.

Defendant Deputy Timothy J. Boxley’s actions deprived Jose Mercado-Nova of

his life without due process of law, constituting a violation of Jose Mercado-Nova’s 14th Amendment U.S. constitutional right.

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50.

Defendant Timothy J. Boxley knew or should have known that his conduct

subjected Jose Mercado-Nova and other members of the public to eminent danger and risk of serious bodily injury, harm and death.

51.

Nevertheless, with reckless disregard for Jose Mercado-Nova’s constitutional

right not to be subjected to serious dangers created by and under the control of the Defendants, protected by the Due Process Clause of the Fourteenth Amendment, Defendant Boxley subjected Jose Mercado-Nova to eminent danger, risk of serious bodily harm and death.

52.

As a direct and proximate result of abuse and misuse of power and position, and

extremely reckless conduct by Defendant Deputy Timothy J. Boxley, Jose Mercado-Nova suffered severe injuries, mental anguish, and ultimately death; and Plaintiffs have suffered grief, sorrow, mental anguish, loss of the companionship of their father, and economic damages.

WHEREFORE, Plaintiffs pray for judgment in their favor and against the Defendants in an amount which will reasonably compensate Plaintiffs for their injuries, damages and losses caused by the Defendants, for pre-judgment and post-judgment interest as provided by law, for costs and expenses, for expert witness fees and attorney’s fees pursuant to law including 42 U.S.C. 1988, and for such other and further relief as the Court determines equitable and just.

PLAINTIFFS REQUEST A JURY TRIAL.

9

Case 1:17-cv-01274-WYD Document 1 Filed 05/25/17 USDC Colorado Page 10 of 10

Dated this 25th day of May 2017.

RAY & HEATHERMAN LAW PLLC

By:

/s/ Steven B. Ray __________________________________ Steven B. Ray, #5435 3500 JFK Parkway, Suite 202 Fort Collins, Colorado 80525 Telephone: 970-266-1210 Facsimile: 970-226-9034 Email: rayheatherman.c Attorneys for Plaintiffs Claudia A. Mercado, Gloria Y. Mercado, James Mercado and the Estate of Jose Mercado-Nova

&

FRANKLIN D. AZAR & ASSOCIATES, P.C. /s/ DezaRae D. LaCrue DezaRae D. LaCrue, #40290 Patricia A. Meester, #29523 14426 East Evans Avenue Aurora, Colorado 80014 Telephone: 303-757-3300 Facsimile: 303-757-3206 Email: lacrued@fdazar.com meesterp@fdazar.com Attorneys for Plaintiff Joe Anthony Mercado

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Case 1:17-cv-01274-WYD Document 1-1 Filed 05/25/17 USDC Colorado Page 1 of 1 JS 44 (Rev. 11/15) District of Colorado Form

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 Board of Commissioners, County of Weld, State of Colorado; Weld County Sheriff's Department; and Weld County Deputy Sheriff Timothy J. Boxley, Individually.

Claudia A. Mercado, Gloria Y. Mercado, James Mercado, & Joe Anthony Mercado, surviving heirs of Jose Mercado-Nova deceased; and The Estate of Jose Mercado-Nova, Claudia A. Mercado Personal Representative,

Weld County, Colorado

(b) County of Residence of First Listed Plaintiff

County of Residence of First Listed Defendant

(EXCEPT IN U.S. PLAINTIFF CASES) NOTE:

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

Weld County, Colorado

(IN U.S. PLAINTIFF CASES ONLY) IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED.

Attorneys (If Known)

DezaRae D. LaCrue, Patricia A. Meester, Franklin D. Azar & Associates, 14426 East Evans Ave., Aurora, CO. 80114, (303)757-3300 and Steven B. Ray, Ray & Heatherman Law, PLLC., 3500 JFK Parkway, Suite 202, Fort Collins, CO. 80525, (970)266-1210.

II. BASIS OF JURISDICTION (Place an “X” in One Box Only) ’ 1

U.S. Government Plaintiff

’ 3

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

’ 2

U.S. Government Defendant

’ 4

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

and One Box for Defendant) PTF DEF Incorporated or Principal Place ’ 4 ’ 4 of Business In This State

Citizen of Another State

’ 2

’

2

Incorporated and Principal Place of Business In Another State

’ 5

’ 5

Citizen or Subject of a Foreign Country

’ 3

’

3

Foreign Nation

’ 6

’ 6

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 Veteran’s 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 IRS—Third Party 26 USC 7609

IMMIGRATION ’ 462 Naturalization Application ’ 465 Other Immigration Actions

OTHER STATUTES ’ 375 False Claims Act ’ 376 Qui Tam (31 USC 3729(a)) ’ 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

V. ORIGIN (Place an “X” in One Box Only) ’ 1 Original Proceeding

’ 2 Removed from State Court

’ 3

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:

motor vehicle collision resulting in death;violation of constitutional protections by state actor

’ 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

AP Docket CHECK YES only if demanded in complaint: ’ Yes ’ No JURY DEMAND:

DEMAND $

DOCKET NUMBER

SIGNATURE OF ATTORNEY OF RECORD

/s/ DezaRae D. LaCrue

05/25/2017 FOR OFFICE USE ONLY RECEIPT #

AMOUNT

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Case 1:17-cv-01274-WYD Document 1-2 Filed 05/25/17 USDC Colorado Page 1 of 2

AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT for the

__________ District of __________ CLAUDIA A. MERCADO, GLORIA Y. MERCADO, JAMES MERCADO, & JOE ANTHONY MERCADO, surviving heirs of JOSE MERCADO-NOVA deceased; and THE ESTATE OF JOSE MERCADO-NOVA, Claudia A. mercado Personal Representative,

Plaintiff(s)

v.

BOARD OF COMMISSIONERS, COUNTY OF WELD, STATE OF COLORADO; WELD COUNTY SHERIFF'S DEPARTMENT; and WELD COUNTY DEPUTY SHERIFF TIMOTHY J. BOXLEY, individually,

Defendant(s)

) ) ) ) ) ) ) ) ) ) ) )

Civil Action No.

SUMMONS IN A CIVIL ACTION To: (Defendant’s name and address)

Board of Commissioners, County of Weld, State of Colorado; 1150 O Street, Greeley, CO 80631 Weld County Sheriff's Department; 1950 O Street, Greeley, CO. 80631 Weld County Deputy Sheriff Timothy J. Boxley, individual; 3891 Jefferson Drive, Loveland, CO 80538

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 plaintiff’s attorney, whose name and address are: DezaRae D. LaCrue, Esq. Patricia A. Meester, Esq. of Franklin D. Azar & Associates, P.C., 14426 East Evans Avenue, Auoroa, CO 80114 & Steven B. Ray, Esq. of Ray & Heatherman Law, PLLC, 3500 JFK Parkway, Suite 202, Fort Collins, CO 80525

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 1:17-cv-01274-WYD Document 1-2 Filed 05/25/17 USDC Colorado Page 2 of 2

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 individual’s 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 individual’s 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: Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

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