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| Date_______________, |
Clerk of the District Court |
| by____________________ | |
| (Seal) |
| Name | Location of Service | Manner of Service | Date | Time |
| (other than above) | ||||
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| (Signature) | |
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Method of Communication (in person or telephone) |
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| (Signature) | |
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| (Name Printed) | |
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| (Title) |
| TO: |
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| (Juvenile) | ||
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| (Father) | ||
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| (Mother) | ||
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| (Other having custody relationship) | (Address) |
| On | ________, | ________, | ______, | at __ o'clock __m. | |
| (day) | (date) | (year) |
| Date: ________, |
Clerk of the District Court |
| (Seal) | by ________________________ |
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| Date Returned: ________, |
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(in person or telephone) |
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| (Signature) | |
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| (Name Printed) | |
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| School | Grade |
| Grades | Good______ | Fair______ | Poor______ |
| Attendance | Good______ | Fair______ | Poor______ |
| Behavior | Good______ | Fair______ | Poor______ |