PROTECTION ORDER – DOMESTIC VIOLENCE
RETURN OF SERVICE
Case No. ____________________
Dept. No. ____________________
__________________________________________________, IN THE JUSTICE COURT OF __________TOWNSHIP
(Name) Applicant, COUNTY OF ___________, STATE OF NEVADA
OR
VS. IN THE ______________ JUDICIAL DISTRICT COURT
OF THE STATE OF NEVADA, IN AND FOR THE
__________________________________________________, COUNTY OF ___________________________________
(Name) Adverse Party.
TYPE OF ORDER SERVED
USE SEPARATE RETURN OF SERVICE FORM FOR PROTECTION ORDERS OTHER THAN DOMESTIC VIOLENCE
The Order shall be served by the constable OR by a deputy; OR by the sheriff of the county where the defendant
is found, OR by a deputy, OR by any person who is not a party and who is over 18 years of age.
I HEREBY CERTIFY THAT ON ________________________________ I RECEIVED:
(DATE)
Temporary Protection Order–Domestic Violence Extended Protection Order-Domestic Violence
Motion/Notice for Hearing - Domestic Violence Protection Order
Order for Hearing to Extend, Modify or Dissolve Domestic Violence-Protection Order
Foreign Order (describe in terms of State/County/City & Court Issued from):
Other (describe): __________________________________________________________________________________________
I DECLARE UNDER PENALTY OF PERJURY THAT I:
PERSONALLY SERVED the same upon the Adverse Party/Applicant__________________________________________,
(Name)
on _______________________ at _____________ , who identified himself/herself by or with:__________________________,
(Date) (Time) (Type of Identification)
at (location): ________________________________________________________________________________________,
City of ________________________________________, County of _________________________, State of Nevada.
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.
INFORMED THE ADVERSE PARTY of the specific terms and conditions of the Order, and that a violation of the
Order will result in his/her arrest; the location of the Court that issued the Order and the hours during which he/she
may obtain a copy of the Order; and the date and time set for hearing.
ATTEMPTED TO SERVE same on: _______________________________, _________________________________, and
____________________________. The Adverse Party/Applicant was not found and service was NOT effected.
SIGNATURE (Officer/Person Serving Order/ID Number)
Print Name (Officer/Person Serving Order) Print Address (Officer/Person Serving Order)
SIGNATURE (Adverse Party/Witness, if applicable) Print Name and Address (Adverse Party/Witness)
