File No. STATE OF NORTH CAROLINA County In The General Court Of Justice District Court Division Name Of Plaintiff Address CIVIL SUMMONS City, State, Zip DOMESTIC VIOLENCE ALIAS AND PLURIES SUMMONS VERSUS G.S. 1A-1, Rules 3, 4Name Of Defendant Date Original Summons Issued Date(s) Subsequent Summons(es) Issued To The Defendant Named Below: Name And Address Of Defendant A Civil Action Has Been Commenced Against You! You are notified to appear and answer the complaint of the plaintiff as follows: 1. Serve a copy of your written answer to the complaint upon the plaintiff or plaintiffs attorney within thirty (30) days after you have been served. You may serve your answer by delivering a copy to the plaintiff or by mailing it to the plaintiffs last known address; and 2. File the original of the written answer with the Clerk of Superior Court of the county named above. If you fail to answer the complaint, the plaintiff will apply to the Court for the relief demanded in the complaint. Name And Address Of Plaintiffs Attorney (If None, Address Of Plaintiff)Date Issued Time AM PM Signature Deputy CSC Assistant CSC Clerk Of Superior Court Date Of Endorsement Time ENDORSEMENT AM PM This Summons was originally issued on the date Signature indicated above and returned not served. At the request of the plaintiff, the time within which this Summons must be served is extended sixty (60) Deputy CSC Assistant CSC Clerk Of Superior Court days. AOC-CV-317, Rev. 12/04 2004 Administrative Office of the Courts (Over) >>>> 2 RETURN OF SERVICE I certify that this Summons and a copy of the complaint and a copy of the ex parte order were received and served as follows: DEFENDANT Date Served Time Served Name Of Defendant AM PM By delivering to the defendant named above a copy of the summons and complaint. By leaving a copy of the summons and complaint at the dwelling house or usual place of abode of the defendant named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left Other manner of service (specify) Defendant WAS NOT served for the following reason: Service Fee Paid Signature Of Deputy Sheriff Making Return$ Date Received Name Of Sheriff (Type Or Print)Date Of Return County Of Sheriff AOC-CV-317, Side Two, Rev. 12/04 2004 Administrative Office of the Courts