3 Respondent (Person From Whom Protection Is Sought)

WV-250

Proof of Service of 
Response by Mail

1 Petitioner (Employer)

2 Employee in Need of Protection

Name:

Name:

Name:

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Notice to Server
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.
Mail a copy of all documents
checked in       below to the petitioner or 
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the petitioner’s lawyer.      
Complete and sign this form and give it 
to the respondent.      

•
•

•

Clerk stamps date here when form is filed.

Fill in court name and street address:
Superior Court of California, County of

Fill in case number:
Case Number:

PROOF OF SERVICE BY MAIL

I am 18 years of age or older and not a party to this proceeding.  I am live or am employed in the county where 
the 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): 

I placed copies of the documents listed above in a sealed envelope and mailed them as described below:

5

6

a.

b.

Mailed to (name):

To this address: 

City:

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Server’s Information

Name:

Address:

City:

Date:

c.

On (date):

Mailed from: City:

State:

Zip:

State:

(If you are a registered process server):

County of registration:

I declare under penalty of perjury under the laws of the State of California that the information above is true and 
correct.

Telephone:

State:

Zip:

Registration number:

Type or print server’s name


Server to sign here

Judicial Council of California, www.courts.ca.gov
Revised January 1, 2012, Optional Form
Code of Civil Procedure, § 527.8 

Proof of Service of Response by Mail
(Workplace Violence Prevention)

WV-250, Page 1 of 1