Free State of Minnesota - Minnesota

State of Minnesota

District Court Judicial District: Court File Number: Case Type:

Select County

Juvenile

In the Matter of the Welfare of the Child(ren) of: Parent Parent State Of Minnesota County Of I,
(Name of person who mailed or hand delivered documents)

Legal Custodian Legal Custodian ) ) SS

Affidavit of Service: Notice of Motion and Motion to Intervene

(County where Affidavit Signed)

, being first duly sworn, upon oath, state , I served the attached Notice of Motion and
(Date Service Made)

that on Motion to Intervene by (check one):

hand delivering the document to the following persons at the following addresses: OR mailing the document to the following person(s) at the following addresses:
1. First Name Street Address City County Last Name Apt. No. State

2. First Name Street Address City County Last Name Apt. No. State

3. First Name Street Address City County Last Name Apt. No. State

CHP406

State

ENG

Rev 7/04-D

www.courts.state.mn.us/forms

Page 1 of 2

4. First Name Street Address City 5. First Name Street Address City 6. First Name Street Address City 7. First Name Street Address City 8. First Name Street Address City County Last Name Apt. No. State County Last Name Apt. No. State County Last Name Apt. No. State County Last Name Apt. No. State County Last Name Apt. No. State

Dated: Signature
(Sign only in front of notary public or court administrator)

Name: Street Address: City/State/Zip: Sworn/affirmed before me this this day of , Notary Public \ Court Administrator

.

CHP406

State

ENG

Rev 7/04-D

www.courts.state.mn.us/forms

Page 2 of 2