STATE OF NORTH CAROLINA County Name Of Plaintiff/Victim Name Of Person Filing On Behalf Of Minor Or Incompetent Victim File No. In The General Court Of Justice District Court Division Name Of Defendant/Respondent VERSUS CIVIL SUMMONS PERMANENT CIVIL NO-CONTACT ORDER AGAINST SEX OFFENDER ALIAS AND PLURIES SUMMONS G.S. 1A-1, Rules 3 and 4; 50D-3 Date Original Summons Issued Date(s) Subsequent Summons(es) Issued To The Defendant Named Below: Name And Address Of Defendant/Respondent A Civil Action Has Been Commenced Against You! You are notified to appear and answer the complaint of the plaintiff as follows: 1. File a written answer in the office of the Clerk of Superior Court for the county named above within ten (10) days of the date you were served. 2. Serve a copy of your answer on the plaintiff or the plaintiff's attorney by personal delivery or mail at the address listed below. 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 Plaintiff's Attorney (If none, Address Of Plaintiff, unless omitted pursuant to G.S. 50D-2(d), in which case, Alternative Address Designated By Plaintiff.) Date Issued Signature Time AM PM Deputy CSC Assistant CSC Clerk Of Superior Court ENDORSEMENT This Summons was originally issued on the date 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) days. Date Of Endorsement Signature Time AM PM Deputy CSC Assistant CSC Clerk Of Superior Court (Over) AOC-CV-541, New 10/15 � 2015 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com RETURN OF SERVICE I certify that this Summons and a copy of the complaint 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: Date Received Date Of Return Signature Of Deputy Sheriff Making Return Name Of Deputy Sheriff Making Return (type or print) County Of Deputy Sheriff Making Return AOC-CV-541, Side Two, New 10/15 � 2015 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com