Santa Clara — FM-1041*

Source: https://santaclara.courts.ca.gov/system/files/forms/fm-1041_rem.pdf

To keep other people from seeing what you have entered, please press Reset Form button when finished. ATTACHMENT FM-1041 Protected Person’s Name: Case Number:

CONFIDENTIAL--DO NOT FILE IN COURT FILE

Request for Sheriff to Serve and Sheriff’s Fee Statement

I WANT THE SHERIFF TO SERVE THE ATTACHED LEGAL FORMS WITHIN SANTA CLARA COUNTY AT NO COST TO ME.

To the Sheriff: Serve the attached legal forms on the Restrained Party in this case. Send a copy of the Proof of Service or any other documents to:

the Protected Party’s Attorney

the Protected Party at the address listed below:

Today’s Date: Sign Your Name Here

Reset Form

Protected Person/Protected Person’s Attorney – Do not fill out anything below this line

INFORMATION BELOW IS TO BE COMPLETED BY SHERIFF’S OFFICE PERSONNEL ONLY

Service of the order was made or attempted on (date):

Fee for Service: $

Type or Print Name of Sheriff’s Office Representative Signature of Law Enforcement Representative

Title of Agency

FM-1041 REV 1/25/08 (non-substantive change 3/3/11) REQUEST FOR SHERIFF TO SERVE AND Page 1 of 1 SHERIFF’S FEE STATEMENT