IN THE UNITED STATES DISTRICT COURT FOR THE 

SOUTHERN DISTRICT OF OHIO 

EASTERN DIVISION 

UNITED STATES OF AMERICA, ) 

 ) 

 Plaintiff, ) 

 ) 

 v. ) 

 ) 

ROBERT L. HOLSINGER, and ) 

TREASURER OF JEFFERSON COUNTY, ) 

 ) 

 Defendants. ) 

_______________________________________) 

Case No. 2:18-cv-00132 

COMPLAINT

The United States, pursuant to 26 U.S.C. § 7401, with the authorization of a delegate of 

the Secretary of the Treasury, and at the direction of a delegate of the Attorney General, brings 

this civil action to reduce to judgment unpaid federal income tax liabilities of Robert L. 

Holsinger and to enforce the federal tax liens that have attached to certain real property that is 

currently held in the name of Defendant Robert L. Holsinger. 

For its Complaint, the United States alleges as follows: 

Jurisdiction and Parties

1. Jurisdiction over this action arises under 28 U.S.C. §§ 1331, 1340, and 1345, and 

26 U.S.C. §§ 7402(a) and 7403. 

 2. Venue is proper under 28 U.S.C. §§ 1391(b) and 1396. 

3. Defendant Robert L. Holsinger (“Holsinger”) resides within the jurisdiction of 

this Court. 

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 4. Defendant Treasurer of Jefferson County is named as a party pursuant to 26 

U.S.C. § 7403(b) because it has or may claim an interest in the real property upon which the 

United States seeks to enforce its liens. 

COUNT I: To Collect Unpaid Federal Income Taxes 

(Defendant Robert L. Holsinger Only) 

5. The United States repeats and re-alleges paragraphs 1-4 above, as though fully set 

forth herein. 

6. A delegate of the Secretary made the following income tax assessments against 

Holsinger, on the dates and in the amounts set forth below: 

Tax Year Assessment 

Date 

Assessment Type Assessed 

Amount 

Balance 

Due as of 

2/19/2018 

2002 6/16/2008 

6/16/2008 

6/16/2008 

6/16/2008 

6/16/2008 

9/29/2008 

Federal Income Tax 

Estimated Tax Penalty 

Late Filing Penalty 

Interest 

Late Payment Penalty 

Collection Fee 

$9,244.00

$140.74

$1,060.88

$2,203.64

$1,178.75

$8.00

$12,883.18

2003 6/16/2008 

6/16/2008 

6/16/2008 

6/16/2008 

6/16/2008 

Federal Income Tax 

Estimated Tax Penalty 

Late Filing Penalty 

Interest 

Late Payment Penalty 

$9,216.00

$94.20

$936.23

$1,634.27

$1,040.25

$11,166.77

2004 6/16/2008 

6/16/2008 

6/16/2008 

6/16/2008 

6/16/2008 

Federal Income Tax 

Estimated Tax Penalty 

Late Filing Penalty 

Interest 

Late Payment Penalty 

$11,716.00

$168.72

$1,440.68

$2,031.39

$1,248.58

$16,383.22

2005 6/23/2008 

6/23/2008 

6/23/2008 

6/23/2008 

6/23/2008 

Federal Income Tax 

Estimated Tax Penalty 

Late Filing Penalty 

Interest 

Late Payment Penalty 

$54,151.00

$661.70

$4,558.95

$4,483.81

$2,735.37

$48,701.58

 TOTAL $89,134.75 

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7. A delegate of the Secretary duly gave Holsinger notice of the tax assessments and 

made a demand for payment of the balance due. 

8. Despite such notice and demand, Holsinger has failed, neglected, or refused to 

pay in full the liabilities described in paragraph 6 above, and, after the application of all 

abatements, payments, and credits, as of February 19, 2018, he remains indebted to the United 

States for unpaid income taxes, and statutory accruals, including interest, in the total amount of 

$89,134.75, plus such additional amounts as may continue to accrue as provided by law, 

including interest pursuant to 26 U.S.C. §§ 6601, 6621, and 6622, and 28 U.S.C. § 1961(c). 

COUNT II: Enforcement of Federal Tax Liens Against the Property 

(All Defendants) 

9. The United States repeats and re-alleges all paragraphs above, as though fully set 

forth herein. 

10. The property upon which the United States is seeking to enforce its tax liens 

(“Property”) is located within the jurisdiction of this Court at 14903 State Route 152, Toronto, 

OH 43964, in Jefferson County, and is legally described as follows: 

Situated in the Township of Knox, County of Jefferson and the State of Ohio; Known as 

and being part of the Northeast quarter of Section 20, Township 8 of Range 2, also Being 

part of a 5.8285 acre tract of Robert E. and Robert Christopher Jones as recorded in 

Volume 137, Page 954, Tract No. 1 of Official records and part of a 29.465 acre tract of 

Robert E. and Christopher Jones as recorded in Volume 137, Page 954, tract No. 2 of 

Official Record, said tract being more particularly described as follows: 

Being at a 3/8” iron pin, with cap, set at the Northeast corner of said Jones 5.8285 acre 

tract and the Southeast corner of a 2.4055 acre tract of F. Allen as recorded in Volume 

67, Page 610, of Official record and THE TRUE PLACE OF BEGINNING: 

Thence with the East line of said quarter section, South 0 degrees 37 minutes 38 seconds 

East 486.00 feet to a 3/8” iron pin, with cap, set; thence North 81 degrees 58 minutes 27 

seconds West 631.47 feet to a 3/8 inch iron pin with cap set; thence North 27 degrees 14 

minutes 25 seconds East 89.20 feet to a 3/8” iron pin, with cap, set; thence South 82 

degrees 10 minutes 26 seconds East 661.25 feet to a 3/8” iron pin, with cap set; thence 

North 60 degrees 21 minutes 41 seconds East 127.39 feet to a 3/8 iron pin, with cap, set; 

thence North 6 degrees 17 minutes 52 seconds West 164.69 feet to a 3/8” iron pin, with 

Case: 2:18-cv-00132-GCS-CMV Doc #: 1 Filed: 02/20/18 Page: 3 of 6 PAGEID #: 3
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cap set; thence North 89 degrees 31 minutes 37 seconds West 59.16 feet to a 3/8 inch iron 

pin with cap, set thence North 7 degrees 25 minutes 07 seconds West 400.85 feet to a 

3/8” iron pin, with cap, set on the North side of State Route 152 on the South side of a 

2.924 acre tract of S.&M. Falls as recorded in Volume 185, Page 472 of Official Record; 

thence with said road and said Fall tract, South 52 degrees 00 minutes 00 seconds East 

71.23 feet to a 3/8” iron pin with cap, set at the Northwest corner of said Allen tract; 

thence with the West line of said Allen tract, South 7 degrees 25 minutes 07 seconds East 

300.11 feet to a 1⁄2” iron pin, with cap, set: thence with the South line of said Allen tract, 

South 89 degrees 31 minutes 37 seconds east 38.67 feet to a 3/8” iron pin, with cap, set; 

thence with the South line of said Allen tract, North 83 degrees 45 minutes 53 seconds 

East 405.56 feet to an iron pin and the TRUE PLACE OF BEGINNING, the herein 

described tract, containing 5.078 acres, more or less, 4.084 acres out of said 5.8285 acres 

and 0.994 acres out of said 39.465 acre tract, subject to all legal highways, easements or 

restrictions of record. 

The basis of bearing was the east line of said quarter section and the bearing of south 0 

deg., 37 min., 38 sec. east was taken from a survey by James Poder on August 4, 1979. 

Description for said tract on survey by Bonar Surveying, Registered Surveyor No. 7134, 

9-28-1986. 

11. By a document dated July 25, 2006, and recorded on July 25, 2006, with the 

Jefferson County Recorder’s Office at Volume 763, Page 564, Clifford E. Hanle Sr., conveyed 

the Property to Robert Lee Holsinger. 

12. Pursuant to 26 U.S.C. §§ 6321 and 6322, as a result of Holsinger’s neglect, 

refusal or failure to pay the liabilities described in paragraph 6 above, after notice and demand, 

federal tax liens arose on the dates of the assessments and attached to all property and rights to 

property belonging to Defendant Robert L. Holsinger, including the Property. 

13. On September 8, 2008, the Internal Revenue Service filed a Notice of Federal Tax 

Lien for the tax assessments made against Robert L. Holsinger for the tax years 2002, 2003, 

2004, and 2005, in the Jefferson County Recorder’s Office. 

14. The United States is entitled to enforce its liens for taxes against the Property, to 

have the Property sold at a judicial sale free and clear of all rights, titles, claims, liens, and 

interests of the parties to this action, including any rights of redemption, and, after the payment 

Case: 2:18-cv-00132-GCS-CMV Doc #: 1 Filed: 02/20/18 Page: 4 of 6 PAGEID #: 4
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of the costs of sale and any real estate taxes due and payable under 26 U.S.C. § 6323(b)(6), to 

have an appropriate portion of the net proceeds applied toward the satisfaction of Robert L. 

Holsinger’s tax liabilities described in paragraph 6 above. 

WHEREFORE the Plaintiff United States of America requests that this Court: 

A. Enter judgment in favor of the Plaintiff United States of America and against the 

Defendant Robert L. Holsinger in the amount of $89,134.75, as of February 19, 2018, plus 

statutory additions from and after February 19, 2018, including interest pursuant to 26 U.S.C. §§ 

6601, 6621, and 6622, and 28 U.S.C. § 1961(c) for the unpaid federal income taxes assessed 

against him. 

B. Determine and adjudge that the United States of America has valid and subsisting 

federal tax liens on all property and rights to property belonging to the Defendant Robert L. 

Holsinger, including the Property; 

 C. Order that the federal tax liens for the liabilities of the Defendant Robert L. 

Holsinger be enforced, and that the Property may be sold by an officer of this Court, according to 

law, free and clear of all rights, titles, claims, liens, and interests of the parties to this action, 

including any right of redemption, with an appropriate portion of the net proceeds of the sale, 

after the payment of the direct costs of sale and any real estate taxes due and payable under 26 

U.S.C. § 6323(b)(6), to be paid to the Plaintiff United States for application to the unpaid federal 

internal revenue tax liabilities of Robert L. Holsinger; and 

 D. Award the United States of America its costs in this action, and such other and 

further relief as the Court determines is just and proper. 

Case: 2:18-cv-00132-GCS-CMV Doc #: 1 Filed: 02/20/18 Page: 5 of 6 PAGEID #: 5
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DATED: February 20, 2018 

RICHARD E. ZUCKERMAN 

Principal Deputy Assistant Attorney General 

Tax Division, U.S. Department of Justice 

__/s/ Philip L. Bednar_________________ 

PHILIP LEONARD BEDNAR 

Trial Attorney, Tax Division 

U.S. Department of Justice 

P.O. Box 55 

Washington, D.C. 20044 

202-307-6415 (v) 

202-514-5238 (f) 

Philip.L.Bednar@usdoj.gov 

WA State Bar No. 41304 

Case: 2:18-cv-00132-GCS-CMV Doc #: 1 Filed: 02/20/18 Page: 6 of 6 PAGEID #: 6
JS 44 (Rev. 06/17) CIVIL COVER SHEET

The JS 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as

provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the

purpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.)

I. (a) PLAINTIFFS DEFENDANTS

(b) County of Residence of First Listed Plaintiff County of Residence of First Listed Defendant

(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)

NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF 

THE TRACT OF LAND INVOLVED.

 

(c) Attorneys (Firm Name, Address, and Telephone Number) Attorneys (If Known)

II. BASIS OF JURISDICTION(Place an “X” in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an “X” in One Box for Plaintiff

(For Diversity Cases Only) and One Box for Defendant) 

’ 1 U.S. Government ’ 3 Federal Question PTF DEF PTF DEF

Plaintiff (U.S. Government Not a Party) Citizen of This State ’ 1 ’ 1 Incorporated or Principal Place ’ 4 ’ 4

 of Business In This State

’ 2 U.S. Government ’ 4 Diversity Citizen of Another State ’ 2 ’ 2 Incorporated and Principal Place ’ 5 ’ 5

Defendant (Indicate Citizenship of Parties in Item III) of Business In Another State

Citizen or Subject of a ’ 3 ’ 3 Foreign Nation ’ 6 ’ 6

 Foreign Country

IV. NATURE OF SUIT (Place an “X” in One Box Only) Click here for: Nature of Suit Code Descriptions.

CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES

’ 110 Insurance PERSONAL INJURY PERSONAL INJURY ’ 625 Drug Related Seizure ’ 422 Appeal 28 USC 158 ’ 375 False Claims Act

’ 120 Marine ’ 310 Airplane ’ 365 Personal Injury - of Property 21 USC 881 ’ 423 Withdrawal ’ 376 Qui Tam (31 USC 

’ 130 Miller Act ’ 315 Airplane Product Product Liability ’ 690 Other 28 USC 157 3729(a))

’ 140 Negotiable Instrument Liability ’ 367 Health Care/ ’ 400 State Reapportionment

’ 150 Recovery of Overpayment ’ 320 Assault, Libel & Pharmaceutical PROPERTY RIGHTS ’ 410 Antitrust

 & Enforcement of Judgment Slander Personal Injury ’ 820 Copyrights ’ 430 Banks and Banking

’ 151 Medicare Act ’ 330 Federal Employers’ Product Liability ’ 830 Patent ’ 450 Commerce

’ 152 Recovery of Defaulted Liability ’ 368 Asbestos Personal ’ 835 Patent - Abbreviated ’ 460 Deportation

 Student Loans ’ 340 Marine Injury Product New Drug Application ’ 470 Racketeer Influenced and

 (Excludes Veterans) ’ 345 Marine Product Liability ’ 840 Trademark Corrupt Organizations

’ 153 Recovery of Overpayment Liability PERSONAL PROPERTY LABOR SOCIAL SECURITY ’ 480 Consumer Credit

 of Veteran’s Benefits ’ 350 Motor Vehicle ’ 370 Other Fraud ’ 710 Fair Labor Standards ’ 861 HIA (1395ff) ’ 490 Cable/Sat TV

’ 160 Stockholders’ Suits ’ 355 Motor Vehicle ’ 371 Truth in Lending Act ’ 862 Black Lung (923) ’ 850 Securities/Commodities/

’ 190 Other Contract Product Liability ’ 380 Other Personal ’ 720 Labor/Management ’ 863 DIWC/DIWW (405(g)) Exchange

’ 195 Contract Product Liability ’ 360 Other Personal Property Damage Relations ’ 864 SSID Title XVI ’ 890 Other Statutory Actions

’ 196 Franchise Injury ’ 385 Property Damage ’ 740 Railway Labor Act ’ 865 RSI (405(g)) ’ 891 Agricultural Acts

’ 362 Personal Injury - Product Liability ’ 751 Family and Medical ’ 893 Environmental Matters

 Medical Malpractice Leave Act ’ 895 Freedom of Information

 REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS ’ 790 Other Labor Litigation FEDERAL TAX SUITS Act

’ 210 Land Condemnation ’ 440 Other Civil Rights Habeas Corpus: ’ 791 Employee Retirement ’ 870 Taxes (U.S. Plaintiff ’ 896 Arbitration

’ 220 Foreclosure ’ 441 Voting ’ 463 Alien Detainee Income Security Act or Defendant) ’ 899 Administrative Procedure

’ 230 Rent Lease & Ejectment ’ 442 Employment ’ 510 Motions to Vacate ’ 871 IRS—Third Party Act/Review or Appeal of

’ 240 Torts to Land ’ 443 Housing/ Sentence 26 USC 7609 Agency Decision

’ 245 Tort Product Liability Accommodations ’ 530 General ’ 950 Constitutionality of

’ 290 All Other Real Property ’ 445 Amer. w/Disabilities - ’ 535 Death Penalty IMMIGRATION State Statutes

 Employment Other: ’ 462 Naturalization Application

’ 446 Amer. w/Disabilities - ’ 540 Mandamus & Other ’ 465 Other Immigration

 Other ’ 550 Civil Rights Actions

’ 448 Education ’ 555 Prison Condition

’ 560 Civil Detainee -

 Conditions of 

 Confinement

V. ORIGIN (Place an “X” in One Box Only)

’ 1 Original

Proceeding

’ 2 Removed from

State Court

’ 3 Remanded from

Appellate Court

’ 4 Reinstated or

Reopened

’ 5 Transferred from

Another District

(specify)

’ 6 Multidistrict

Litigation -

Transfer

’ 8 Multidistrict

 Litigation - 

 Direct File

VI. CAUSE OF ACTION

Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):

Brief description of cause:

VII. REQUESTED IN

 COMPLAINT:

’ CHECK IF THIS IS A CLASS ACTION

UNDER RULE 23, F.R.Cv.P.

DEMAND $ CHECK YES only if demanded in complaint:

JURY DEMAND: ’ Yes ’ No

VIII. RELATED CASE(S)

 IF ANY (See instructions):

JUDGE DOCKET NUMBER

DATE SIGNATURE OF ATTORNEY OF RECORD

FOR OFFICE USE ONLY

RECEIPT # AMOUNT APPLYING IFP JUDGE MAG. JUDGE

Case: 2:18-cv-00132-GCS-CMV Doc #: 1-1 Filed: 02/20/18 Page: 1 of 2 PAGEID #: 7
JS 44 Reverse (Rev. 06/17)

INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS 44

Authority For Civil Cover Sheet

The JS 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading or other papers as

required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is

required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk of

Court for each civil complaint filed. The attorney filing a case should complete the form as follows:

I.(a) Plaintiffs-Defendants. Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, use 

only the full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and 

then the official, giving both name and title.

 (b) County of Residence. For each civil case filed, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at the 

time of filing. In U.S. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: In land 

condemnation cases, the county of residence of the "defendant" is the location of the tract of land involved.)

 (c) Attorneys. Enter the firm name, address, telephone number, and attorney of record. If there are several attorneys, list them on an attachment, noting

in this section "(see attachment)".

II. Jurisdiction. The basis of jurisdiction is set forth under Rule 8(a), F.R.Cv.P., which requires that jurisdictions be shown in pleadings. Place an "X" 

in one of the boxes. If there is more than one basis of jurisdiction, precedence is given in the order shown below.

United States plaintiff. (1) Jurisdiction based on 28 U.S.C. 1345 and 1348. Suits by agencies and officers of the United States are included here.

United States defendant. (2) When the plaintiff is suing the United States, its officers or agencies, place an "X" in this box.

Federal question. (3) This refers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution of the United States, an amendment 

to the Constitution, an act of Congress or a treaty of the United States. In cases where the U.S. is a party, the U.S. plaintiff or defendant code takes 

precedence, and box 1 or 2 should be marked.

Diversity of citizenship. (4) This refers to suits under 28 U.S.C. 1332, where parties are citizens of different states. When Box 4 is checked, the 

citizenship of the different parties must be checked. (See Section III below; NOTE: federal question actions take precedence over diversity 

cases.)

III. Residence (citizenship) of Principal Parties. This section of the JS 44 is to be completed if diversity of citizenship was indicated above. Mark this

section for each principal party.

IV. Nature of Suit. Place an "X" in the appropriate box. If there are multiple nature of suit codes associated with the case, pick the nature of suit code 

that is most applicable. Click here for: Nature of Suit Code Descriptions. 

V. Origin. Place an "X" in one of the seven boxes.

Original Proceedings. (1) Cases which originate in the United States district courts.

Removed from State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.C., Section 1441. 

When the petition for removal is granted, check this box.

Remanded from Appellate Court. (3) Check this box for cases remanded to the district court for further action. Use the date of remand as the filing 

date.

Reinstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date.

Transferred from Another District. (5) For cases transferred under Title 28 U.S.C. Section 1404(a). Do not use this for within district transfers or 

multidistrict litigation transfers.

Multidistrict Litigation – Transfer. (6) Check this box when a multidistrict case is transferred into the district under authority of Title 28 U.S.C. 

Section 1407. 

Multidistrict Litigation – Direct File. (8) Check this box when a multidistrict case is filed in the same district as the Master MDL docket. 

PLEASE NOTE THAT THERE IS NOT AN ORIGIN CODE 7. Origin Code 7 was used for historical records and is no longer relevant due to 

changes in statue.

VI. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. Do not cite jurisdictional 

statutes unless diversity. Example: U.S. Civil Statute: 47 USC 553 Brief Description: Unauthorized reception of cable service

VII. Requested in Complaint. Class Action. Place an "X" in this box if you are filing a class action under Rule 23, F.R.Cv.P.

Demand. In this space enter the actual dollar amount being demanded or indicate other demand, such as a preliminary injunction.

Jury Demand. Check the appropriate box to indicate whether or not a jury is being demanded.

VIII. Related Cases. This section of the JS 44 is used to reference related pending cases, if any. If there are related pending cases, insert the docket 

numbers and the corresponding judge names for such cases.

Date and Attorney Signature. Date and sign the civil cover sheet.

Case: 2:18-cv-00132-GCS-CMV Doc #: 1-1 Filed: 02/20/18 Page: 2 of 2 PAGEID #: 8
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Case: 2:18-cv-00132-GCS-CMV Doc #: 1-2 Filed: 02/20/18 Page: 1 of 2 PAGEID #: 9
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

’ I personally served the summons on the individual at (place)

on (date) ; or

’ I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

’ I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

’ I returned the summons unexecuted because ; or

’ Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

Case: 2:18-cv-00132-GCS-CMV Doc #: 1-2 Filed: 02/20/18 Page: 2 of 2 PAGEID #: 10
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Case: 2:18-cv-00132-GCS-CMV Doc #: 1-3 Filed: 02/20/18 Page: 1 of 2 PAGEID #: 11
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

’ I personally served the summons on the individual at (place)

on (date) ; or

’ I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

’ I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

’ I returned the summons unexecuted because ; or

’ Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

Case: 2:18-cv-00132-GCS-CMV Doc #: 1-3 Filed: 02/20/18 Page: 2 of 2 PAGEID #: 12