Form 16C

Courts of Justice Act

CERTIFICATE OF SERVICE BY SHERIFF

(If a separate document insert general heading)

CERTIFICATE OF SERVICE BY SHERIFF

(Personal service)

I, (full name), Sheriff (or Sheriff’s Officer) of the (County, District, etc.) of ..........................., certify that on (date), at (time), I served (identify person served) with (identify documents served) by leaving a copy with him (or her) at (address where service was made).  (Where the rules provide for personal service on a corporation, etc., by leaving a copy of the document with another person, substitute: by leaving a copy with (identify person by name and title) at (address where service was made).)

I was able to identify the person by means of (state the means by which the person’s identity was ascertained.)

(Service by leaving a copy with an adult person in the same household as an alternative to personal service)

I, (full name), Sheriff (or Sheriff’s Officer) of the (County, District, etc.) of ..........................., certify that I served (identify person served) with this document by leaving a copy in a sealed envelope addressed to him (or her) on (date), at (time), with a person (insert name if known) who appeared to be an adult member of the same household in which (identify person served) is residing at (address where service was made), and by sending a copy by regular lettermail (or registered mail) on (date) to (identify person served) at the same address.

I ascertained that the person was an adult member of the household by means of (state how it was ascertained that the person was an adult member of the household).

Before serving the document in this way, I made an unsuccessful attempt to serve (identify person) personally at the same address on (date).  (If more than one attempt has been made, add: and again on (date).)

Date ....................................................................................................		.........................................................................................................
		(Signature of sheriff or sheriff’s officer)

RCP-E 16C (November 1, 2005)