Free STATE OF MINNESOTA - Minnesota

M.S. § 524.5-113

State of Minnesota

Select County County of __________________

District Court Probate Division Judicial District: ______________ Court File No. _________________ Case Type: 14, Conservatorship

Guardianship In Re: Conservatorship of ___________________________

Affidavit of Service by Mail

________________________________________________________being first sworn, says that on (date) ____________, 20____ he/she served (name document served) ___________________ ______________________________________________________________________________ on the following persons by mail: 1. Ward / Protected Person: Name: ____________________________________ Address: ____________________________________ ____________________________________ ____________________________________ ____________________________________ 2. Interested Parties: Relationship Name Address a) Spouse (include an adult with whom Respondent has resided for six months or more):

GAC 3-U

State

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Rev 12/03

www.courts.state.mn.us/forms

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M.S. § 524.5-113

b) Kindred: (adult children, parents and adult brothers and sisters; if none of these, then list the nearest adult kin; See M.S. § 524.5-303(b)(3) and 524.5-102 subd. 7)

c) Administrator (if Respondent is in a hospital, nursing home, VA unit, home care agency or other institution):

GAC 3-U

State

ENG

Rev 12/03

www.courts.state.mn.us/forms

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M.S. § 524.5-113

d) Legal Representative (guardian/conservator, representative payee, trustee or custodian of property):

e) Persons serving as guardian or conservator:

f) Other persons:

________________________________________ Signature of Affiant Sworn/affirmed before me this __________________________________. __________________________________ Notary Public \ Deputy Court Administrator THIS FORM MUST BE COMPLETED AND RETURNED TO THE COURT WITH A COPY OF THE DOCUMENT MAILED TO EACH PERSON

GAC 3-U

State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 3 of 3