Mendocino — WV-250

Source: http://www.courts.ca.gov/documents/wv250.pdf

Proof of Service of Clerk stamps date here when form is filed. WV-250 Response by Mail 1 Petitioner (Employer or Collective Bargaining Representative) Name: 2 Employee Who Suffered Harassment, Violence, or Threat of Violence Name: 3 Respondent (Person From Whom Protection Is Sought) Name: Fill in court name and street address: 4 Notice to Server Superior Court of California, County of The server must: Be 18 years of age or older. Be a resident of or employed in the county where the mailing took place. Not be the respondent. Court fills in case number when form is filed. Mail a copy of all documents checked in Case Number: 5 below to the petitioner or the petitioner’s lawyer. Complete and sign this form and give it to the respondent. PROOF OF SERVICE BY MAIL I am 18 years of age or older and not a party to this proceeding. I live or am employed in the county where the 5 mailing took place. I mailed the petitioner or the petitioner’s lawyer a copy of: a. Form WV-120, Response to Petition for Workplace Violence Restraining Order (completed) b. Other (specify):

6 I placed copies of the documents listed above in a sealed envelope and mailed them as described below: a. Mailed to (name): b. To this address: City: State: Zip: c. On (date): Mailed from: City: State: 7 Server’s Information Name: Telephone: Address: City: State: Zip: (If you are a registered process server): County of registration: Registration number: I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Date:

Type or print server’s name Server to sign here

Judicial Council of California, www.courts.ca.gov WV-250, Page 1 of 1Revised January 1, 2025, Optional Form Proof of Service of Response by Mail Code of Civil Procedure, § 527.8 (Workplace Violence Prevention)

For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form