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AO 111 (Rev. 12/89) Subpoena to Testify before Grand Jury RETURN OF SERVICE RECEIVED Date Place BY SERVER SERVED Date Place SERVED ON (PRINT NAME) SERVED BY (PRINT NAME) TITLE STATEMENT OF SERVICE FEES TRAVEL SERVICES TVLOL DECLARATION OF SERVER I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct. Executed on Date Signature of Server Address of Server ADDITIONAL INFORMATION are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)".