IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN ) ) ) ) ) ) ) ) ) CASE NO:__________________________ AFFIDAVIT OF PROOF OF SERVICE [Elderly Persons and Persons with Disabilities Abuse Prevention Act]
_____________________________________
Petitioner (your name) Guardian Petitioner,
vs. _____________________________________ Respondent (person to be restrained)
STATE OF OREGON County of ______________________
) ) ss. )
I, _______________________________________________________, swear/affirm under oath that: I am a resident of the State of Oregon or of the state of service. I am a competent person 18 years of age or older. I am not an attorney for or a party to this case, or an officer, director or employee of any party to this case. On the __________ day of ____________________, 20____, I served the Restraining Order to Prevent Abuse; Petitioner's/Guardian Petitioner's Petition for Restraining Order to Prevent Abuse; and the Notice to Respondent/ Request for Hearing; Notice to Elderly Person or Person with Disabilities/Objections Form/Request for Hearing; and other documents (list):_____________________________________________ in this case personally upon the above-named respondent elderly or disabled person (name): _____________________________________________________________ in ____________________ County, State of ____________________ by delivering to the respondent or elderly or disabled person a copy of those papers, each of which was certified to be a true copy of each original. ________________________________ Signature of Process Server ____________________________________ Address
________________________________ Print or Type Name of Process Server Telephone Number (s):____________________________________ SUBSCRIBED and SWORN to before me this ______ day of __________________, 20__, by ________________________________. __________________________________________ __________________________________________
NOTARY PUBLIC FOR OREGON / COURT CLERK
My Commission Expires: __________________
ELDER - 4