NYC 9/11 Public Portal Document
AFFIDAVIT (CERTIFICATE-) OF SERVICE
State ol New York, County o! ) ss;
The undersigned being duly sworn’ deposes and says: That deponent is notaparty to the action and is over 18 years of age; Thai on, ia AM/PM
DATE Tier
at deponent served the within Notice of Violation and
LOCATION
Hearing on the respondent named herein.
I. Individual; Personal Service
I I by delivering a true copy to said respondent personally.
II. Individual; Substituted Service
Q i>y delivering a true copy to a parson of suitable age and discretion. Said premises is respondent’s
NAME
actua/ place ol business, dwelling house or usual place ol abode within tho State.
'll. Corporation
I 1 by delivering a true copy to. at said corporation.
NAME POSIT :ON
V. Oelly^ to Employee at Premises
by delivering a true copy to respondent's employee at the above location: (answer A and B)
a” I attempted to personally serve the herein Notice of Violation on the respondent named herein but was unable to do so because, having entered the premises and having Identified
myselM was:
1, Ivised by that Iha tespondonl was not then present, and premises is neither respondent’s actual place of business nor dwelling house.
2. Q unable to secure identification of the pBrson(s) present;
3. I I advised by____ .jj-jjj_____________________ that no officer, director, managing agent or agent of respondent co^ratiog was present.
B. Thereupon, I delivered a copy of the herein Notice of Violation to________________ ______________________ ___ _________________ t ______
NAue • posmoM
whonyrtialieve to ba an employee of respondent al the premises because; (check 1, 2 or 3)
1. Employee so identified him/herself;
2. I I Employee was perlcrming work consistent with being employed by tho respondent; or
3. □ Olher:___ _______________________________________________
fescrlptlon of Individual. (This must be completed (or all types of service except corporate. Number III, above.)
)p3^nt describes the individual s^od as follows:
I^Uale MhiA/hitu Skin r<p^ack Hair □ 14-20 n Under 5' □ Under 100 lbs
J Female D Black Skin □ Brown Hair □ 21^36' □ 5'0'‘5'3" □ 100-130
O Yellow Skin n Blond Hair f^-50 □ 5'4"5'8'' a 131-160
O Brown Skin n Gray Hair ■ □ 51-65 ' n 5'9;-6'0" r^2ob;
LT Red Skin □ Red Hair O Over 65 iX^rB' n Over 200
n White Hair
CT Balding
fiber identifying characteristics:
SfGNATune
Tax R£!
I PH I
Sworn to before me on
.. SiON^UftE OP Ctl
If not sworn, this statement shall constitute d'certificate of seivico.
:■ i
NYC-WTC_000168850
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