To (here insert the name of the defendant and defendant's last known address.)
You will take notice that original process in the suit against you, a copy of which is attached hereto, was duly served upon you at Jefferson City, Missouri, by serving the same on (here insert the name of the public official.)
Dated at __________, Missouri, this _____ day of ___________, 19____
______________________
(appropriate official)
Mo. R. Civ. P. 54.15