Free State of Minnesota - Minnesota

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

District Court
Juvenile

In the Matter of the Welfare of the Child(ren) of:
Parent Parent Legal Custodian Legal Custodian

Affidavit of Service: Notice of Intervention as a A Party as a Matter of Right

State Of Minnesota County Of

) ) SS

(County where Affidavit Signed)

I,
(Name of person who mailed or hand delivered documents)

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

that on

as a Matter of Right by (check one): hand delivering the document or mailing the document to the following person(s) at the following addresses:
1. First Street Address City County Middle Last Apt. No. State

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

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

CHP405

State

ENG

Rev 3/04-D

www.courts.state.mn.us/forms

Page 1 of 2

4. First Street Address City County Middle Last Apt. No. State

5. First Street Address City 6. First Street Address City 7. First Street Address City 8. First Street Address City County Middle Last Apt. No. State County Middle Last Apt. No. State County Middle Last Apt. No. State County Middle Last 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 day of , this Notary Public \ Court Administrator .

CHP405

State

ENG

Rev 3/04-D

www.courts.state.mn.us/forms

Page 2 of 2