Free State of Minnesota - Minnesota

State of Minnesota
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District Court
Judicial District: Court File Number: Case Type:

, Plaintiff/Petitioner And . Defendant/Respondent Date Case Filed: This Certificate must be filed pursuant to Rule 104 of the General Rules of Practice for the District Courts, which states: "A party filing a civil case shall, at the time of filing, notify the Court Administrator in writing of the name, address and telephone number of all counsel and unrepresented parties, if known (see form 104 appended to these rules). If that information is not then known to the filing party, it shall be provided to the Court Administrator in writing within seven (7) days of learning the information. Any party impleading additional parties shall provide the same information to the Court Administrator. The Court Administrator shall, upon receipt of the completed certificate, notify all parties or their lawyers, if represented by counsel, of the date of filing the action and the file number assigned."

Certificate of Representation and Parties

PETITIONER, Self-represented

RESPONDENT, Self-represented

Name

Name

Street Address

Street Address

City

State

Zip Code

City

State Zip Code

Telephone Number

Telephone Number

Note: If either Petitioner or Respondent gets an attorney, the attorney's name, address, telephone number and attorney ID number must be given in writing to the Court Administrator immediately.

CIV102

State

ENG

Rev 12/01-D

www.courts.state.mn.us/forms

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