_____________________________________(Name of deliverer), being duly sworn, deposes and says that he/she is over the age of eighteen years and is not a party in this proceeding; that on the _______ (date) day of ______________ (month/year), at __________________________ (street address), in the town of ______________, county of ________________, State of New York, he/she served the annexed ______________________________________________ (notice, petition, and memorandum in support of petition or answer) on ____________________________ (school district's name) by delivering to and leaving with said ________________________ (receiver of papers) at said time and place a true copy thereof.

Deponent further says he/she knew the person so served to be the said _______________ (receiver of paper), who is ____________________ (position of receiver) in said district.

                                                                                                        _____________________
                                                                                                            (signature)

Subscribed and sworn to before me
this ________ (date) day of _______________ (Month and Year).

_______________________________
(Notary Public)