PNW-0101 Approved 07-01-03 State of Indiana County of _________ (standard caption) _________________ ) ) ) v. ) ) ) ___________ ) SS: Case No. ________________ RETURN OF SERVICE INFORMATION FOR PROTECTIVE ORDERS, NO CONTACT ORDERS AND WORKPLACE VIOLENCE RESTRAINING ORDERS (Under Ind. Code § 5-2-9-6 (b) (3)) Date of service: _____________________________________ Time of service:___________________________ a.m. or p.m. Person served: ____ Respondent/Defendant ____ Other person (Insert name ) ______________________________ Location served: Service occurred at the following location (insert street address, city, county of service): ________________________________________________________________________ Served by: (Insert name and identification or badge number) ________________________________________________________________________ Manner of service: ____ Personal service to Respondent/Defendant ____ Served on the Respondent/Defendant in open court ____ Certified mail to Respondent/Defendant ____ Leaving a copy at last known address of Respondent/Defendant and mailing a copy U.S. mail first class to the Respondent/Defendant's last known address ____ Other _______________ This document was delivered to: ______Sheriff (s) ________________________________________________________ ________________________________________________________________ ______Law enforcement agency (s) __________________________________________ _________________________________________________________________ _________________ Date ___________________________________ Clerk/Deputy Clerk American LegalNet, Inc. www.FormsWorkflow.com