Government of Ontario

Financial Services Commission of Ontario

Dispute Resolution Group

Affidavit of Service
for Summons to Witness
Form O

This is a three part form.
White – Financial Services Commission of Ontario
Yellow – Insurance Company
Pink – Insured Person

The purpose of this Affidavit is to verify that a copy of the document named was personally served on the named person. An Affidavit of Service for Summons to Witness must be prepared for service of a Summons.

Case Information



Declaration

I, ,
of the of
in the of

SWEAR OR SOLEMNLY AFFIRM THAT:

(1) At a.m/p.m. on , the of ,20 ,
I personally served
with a copy of
at

(2) I was able to identify the person by

(3) For a Summons to Witness, I paid the appropriate attendance monies to the person served, named above.

Signatures

Sworn (or Solemnly Affirmed) before me at the
of
In the of
on this of ,20 ,