I (the server) am 18 years of age or over and live in or am employed in
the county where the mailing took place. I mailed a copy of all
documents checked below to the person in :
Not be listed in items or or
of form DV-100, Request for Domestic
Violence Restraining Order.
I declare under penalty of perjury under the laws of the State of California that the information above is true and
DV-250, Page 1 of 1
Judicial Council of California, www.courts.ca.gov
Rev. January 1, 2012, Optional Form
Family Code, §§ 6324, 6340-6344
Proof of Service by Mail (CLETS)
(Domestic Violence Prevention)
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California , Cou nt y of
Fill in case number:
Proof of Service by Mail
Name of Person Asking for Protection:
Name of Person to Be Restrained:
Notice to Server
The server must:
Be 18 years of age or over.
Mail a copy of all documents
to the person in .
(If you are a registered process server):
County of registration:
DV-112, Waiver of Hearing on Denied Request for Temporary
FL-150, Income and Expense Declaration
FL-155, Simplified Financial Statement
DV-130, Restraining Order After Hearing (Order of Protection)
Note: You cannot serve DV-100, DV-105, DV-109, or DV-110 by mail.
I placed copies of the documents checked above in a sealed envelope and mailed them as described below:
To this address:
Name of person served:
DV-120, Response to Request for Domestic Violence Restraining Order
Mailed on (date):
Type or print server’s name
Server to sign here
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button after you have printed the form.