(e)Signature. The officer or authorized person who serves or attempts to serve a citation must sign the return. If the return is signed by a person other than a sheriff, constable, or clerk of the court, the return must either be verified or be signed under penalty of perjury. A return signed under penalty of perjury must contain the statement below in substantially the following form: A My name is (First) (Middle) (Last) , my date of birth is (Month) (Day), (Year) , and my address is (Street), (City), (State) (Zip Code), (Country) . I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of , on the day of (Month) , (Year) .
Declarant"