Free PROOF OF SERVICE OF COMPLETED RESPONSE (Workplace Violence) - Indiana

WV-0105

Approved 07-01-02

) )SS: COUNTY OF ____________)

STATE OF INDIANA

IN THE __________________COURT___ (_______________DIVISION, ROOM___) CASE NO.__________________________

PLAINTIFF: ___________________________________________ DEFENDANT: _________________________________________ EMPLOYEE: __________________________________________ PROOF OF SERVICE OF COMPLETED RESPONSE (Workplace Violence) Instructions to Defendant: After having the other party served with the completed Response to Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee, have the person who served the documents complete this Proof of Service of Completed Response. Give the completed Proof of Service of Completed Response to the clerk for filing. The defendant cannot serve these papers. 1. 2. 3. 4. At the time of service I was at least 18 years of age and not a party to this legal action. I served a copy of the completed Response to Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee. Person served (name): ______________________________________________ By personally delivering copies to the person served, as follows: a. Date: _________________ b. Time: _________________ c. Address: ___________________________________________________ My residence or business address is (specify): ___________________________ ________________________________________________________________ My telephone number is (specify): _________________________________

5. 6.

I affirm, under the penalties for perjury, that the foregoing representations are true. Date: ___________________

_________________________________
(TYPE OR PRINT NAME)

______________________________
(SIGNATURE)

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WV-0105

Approved 07-01-02

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, attorney registration number, and address):

TELEPHONE NO.: ATTORNEY FOR (Name):

FAX NO.:

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