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CCA-DC-1220-1073
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STATE OF INDIANA IN THE COURT
COUNTY OF CASE NO._______________________________
IN RE THE MARRIAGE OF:
__________________________
Petitioner,
v.
__________________________
Respondent.
VERIFIED WAIVER OF SERVICE OF PROCESS and ACKNOWLEDGEMENT OF
RECEIPT OF PETITION FOR DISSOLUTION (DIVORCE) AND SUMMONS
Comes now Respondent ____________________________________________, self-
represented, and states the following:
1. I have received a copy of the Verified Petition for Dissolution of Marriage and Summons
which were both filed on ___________________________________.
2. I waive formal service of the Verified Petition for Dissolution of Marriage and Summons and
do not want another copy of either to be delivered to me by certified mail, a hired process server,
or sheriff.
I affirm under penalties for perjury that the foregoing representations and statements
are true.
__________________________
Respondent Signature
__________________________
Respondent Printed Name
STATE OF INDIANA
COUNTY OF ______________________
Before me, _______________________________, a notary public in and for
__________________________ County, State of Indiana, personally appeared
_______________________________________ and having been duly sworn upon their oath says
that the facts all alleged in the foregoing instrument are true.
Date: _______________________________ ____________________________________
Notary Public
My Commission Expires ____________________________________________
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