Case Name:   _______________________________________________, Petitioner, vs.

                              _______________________________________________, Respondent

        Docket No.     ______________________ File No. ________________

        Order Entered ______________________ (Date)

 State of New York )
 County of Broome ) ss:

         I, ___________________________, being duly sworn, depose and say that I am over 18 years of age and that I reside at ________________________________________________________________________________ ________________________________________________________________________________.

         Deponent affirms that on __________________________ deponent served a copy of the within OBJECTIONS/REBUTTAL to the order entered, in this matter upon the following persons at the addresses stated below, by depositing the same in a postpaid, properly addressed envelope, in a post office or official depository under the exclusive care and custody of the United States Postal Service, within the State of New York as follows:

    1.  Name     _________________________________________________________________
         Address _________________________________________________________________
    2.  Name     _________________________________________________________________
         Address _________________________________________________________________
    3.  Name     _________________________________________________________________
         Address _________________________________________________________________
    4.  Name     _________________________________________________________________
         Address _________________________________________________________________

Date: ___________________________

                                                                  ____________________________________________
                                                                                 Signature of Person Mailing
                                                                                     Objections or Rebuttal

Subscribed and sworn to before me
this ____ day of __________, 20___

______________________________
             Notary Public