STATE OF NEW YORK

COUNTY OF _____________________ss.:

______________________________________, being duly sworn, deposes and says that he/she is over the age of eighteen years and is the local educational agency liaison for homeless children and youth for the _______________________________ school district; that on the ____day of _______________________, 20 ____, deponent served the within ___________upon _______________________________________ in this action, at _____________________________________________________________________, the address designated by ________________________________________________ for that purpose, by depositing a true copy of the same by mail, enclosed in a post paid wrapper addressed to the named school district employee or officer or a person in the office of the superintendent who has been designated by the board of education to accept service on behalf of the school district, in (check one) _______ a post office ________ official depository (mailbox) under the exclusive care and custody of the United States Post Office Department.

____________________
(Signature)

 

Subscribed and sworn to before me this ____ day of ________ 20 ______

 

______________________________
(Signature of notary public)