IN THE COURT OF ____________________ COUNTY, MISSISSIPPI

A. B., Plaintiff(s)

(include appropriate designation of other plaintiffs)

C. D., Defendant(s)

v.

Civil Action, File No.___________________

(include appropriate designation of other defendants)

NOTICE

TO: (Insert the name and address of the person to be served)

The enclosed summons and complaint are served pursuant to Rule 4(c)(3) of the Mississippi Rules of Civil Procedure.

You must sign and date the acknowledgement at the bottom of this page. If you are served on behalf of a corporation, unincorporated association (including a partnership), or other entity, you must indicate under your signature your relationship to that entity. If you are served on behalf of another person and you are authorized to receive process, you must indicate under your signature your authority.

If you do not complete and return the form to the sender within 20 days of the date of mailing shown below, you (or the party on whose behalf you are being served) may be required to pay any expenses incurred in serving a summons and complaint.

If you do complete and return this form, you (or the party on whose behalf you are being served) must respond to the complaint within 30 days of the date of your signature. If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint.

I declare that this Notice and Acknowledgement of Receipt of Summons and Complaint was mailed on ______________________ (Insert date)

_____________________________________

Signature

THIS ACKNOWLEDGEMENT OF RECEIPT OF SUMMONS AND

COMPLAINT MUST BE COMPLETED

I acknowledge that I have received a copy of the summons and of the complaint in the above-captioned matter in the State of ______________________.

____________________________________

Signature

(Relationship to Entity/Authority

to Receive Service of Process)

_____________________________

Date of Signature

State of ____________________)

County of ___________________)

Personally appeared before me, the undersigned authority in and for the State and County aforesaid, the above named _______________________________, who solemnly and truly declared and affirmed before me that the matters and facts set forth in the foregoing Acknowledgement of Receipt of Summons and Complaint are true and correct as therein stated.

Affirmed and subscribed before me this ________ day of _______________, 19_______ .

______________________________

Notary Public

My Commission Expires:______________________

(Seal)