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IN THE DISTRICT COURT FOR THE 		 JUDICIAL DISTRICT
FOR THE STATE OF IDAHO, IN AND FOR THE COUNTY OF 				

						,
		PETITIONER,
	vs.

						,
		RESPONDENT.

State of Idaho, Department of Health and Welfare	
Case No. 					

ACKNOWLEDGMENT OF SERVICE	

I, 					,  Father  Mother, or  Deputy Attorney General for the Department of Health and Welfare in the above-entitled action, admit and acknowledge that service of a copy of the 																															
 was made on me because I received them on (date received)	   				.
I certify that (check all that apply):
 I am not in the uniformed services as defined by the Servicemembers Civil Relief Act; or
 I am in the uniformed services as defined by the Servicemembers Civil Relief Act.  I understand and waive my rights under the Act; or
 I am in the uniformed services as defined by the Servicemembers Civil Relief Act.  I do not waive my rights under the Act.  
  I submit to the jurisdiction of this court, decline to plead, waive hearing, and agree that a final decree or judgment be entered.

Date: 				

		 			Signature
	
STATE OF IDAHO		)
)  ss.
County of   			)  

On this 	 day of 		, before me, the undersigned, a Notary Public in and for the State, personally appeared 					, known or identified to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that s/he executed the same.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on the date last above written.
						
Notary Public for Idaho
Residing at 					
Commission expires