STATE OF NORTH CAROLINA County Name Of Petitioner/Employer File No. In The General Court Of Justice District Court Division CIVIL SUMMONS WORKPLACE VIOLENCE PREVENTION ACT VERSUS Name Of Respondent Date Original Summons Issued ALIAS AND PLURIES SUMMONS G.S. 1A-1, Rules 3, 4; -95-263 Date(s) Subsequent Summons(es) Issued To The Respondent Named Below: Name And Address Of Respondent A Civil Action Has Been Commenced Against You! You are notified to appear and answer the complaint of the petitioner as follows: 1. File a written answer in the office of the Clerk of Superior Court for the county named above within 10 days of the date you were served. 2. Serve a copy of your answer on the petitioner or the petitioner's attorney by personal delivery or mail at the address listed below. If you fail to answer the complaint, the petitioner will apply to the Court for the relief demanded in the complaint. Name And Address Of Petitioner's Attorney (If None, Address Of Petitioner) Date Issued Time AM Signature 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 petitioner, the time within which this Summons must be served is extended sixty (60) days. Date Of Endorsement Time AM Signature PM Deputy CSC Assistant CSC Clerk Of Superior Court AOC-CV-531, New 7/11 � 2011 Administrative Office of the Courts (Over) RETURN OF SERVICE I certify that this Summons and a copy of the complaint and Temporary No-Contact Order Hearing on a No-Contact Order were received and served as follows: RESPONDENT Date Served Time Served Name Of Respondent and Notice Of AM PM By delivering to the respondent 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 respondent named above with a person of suitable age and discretion then residing therein. Name And Address Of Person With Whom Copies Left Respondent WAS NOT served for the following reason: Date Received Signature Of Deputy Sheriff Making Return Name Of Deputy Sheriff (Type Or Print) Date Of Return County Of Sheriff AOC-CV-531, Side Two, New 7/11 � 2011 Administrative Office of the Courts