STATE OF INDIANA ) )SS: COUNTY OF ____________) IN THE __________________COURT___ (_______________DIVISION, ROOM___) CASE NO.__________________________ PLAINTIFF: ___________________________________________ DEFENDANT: _________________________________________ EMPLOYEE: __________________________________________ PROOF OF PERSONAL SERVICE (Workplace Violence) Instructions to Plaintiff: After having the other party served with any of the documents identified in Paragraph 2, have the person who served the documents complete this Proof of Personal Service. Give the completed Proof of Personal Service to the clerk for filing. The plaintiff cannot serve these papers. 1. 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 following documents (check the box before the title of each document you served): a. __ Order to Show Cause (Workplace Violence) __ and Temporary Restraining Order b. __ Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee c. __ Application for Temporary Restraining Order d. __ Response to Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee (blank form WV-0104) e. __ Proof of Service of Completed Response f. __ Order After Hearing on Petition for Injunction Prohibiting Violence or Threats of Violence Against Employee g. __ other (specify): ____________________________________________ __________________________________________________________ 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): ___________________________ ________________________________________________________________ 2. 3. 4. 5. Page 1 of ____ pages TCM-WV-0103 Approved 07/02 Rev. by State Ct. Admin. 07/03 American LegalNet, Inc. www.FormsWorkFlow.com 6. My telephone number is (specify): _________________________________ I affirm, under the penalties for perjury, that the foregoing representations are true. Date: ___________________ _________________________________ (TYPE OR PRINT NAME) ______________________________ (SIGNATURE) ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, attorney registration number, and address): TELEPHONE NO.: FAX NO.: ATTORNEY FOR (Name): Page 2 of ____ pages TCM-WV-0103 Approved 07/02 Rev. by State Ct. Admin. 07/03 American LegalNet, Inc. www.FormsWorkFlow.com