Free State of Minnesota - Minnesota

State of Minnesota County

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



In Re the Marriage of:

Plaintiff / Petitioner

Notice of Order to a Payor of Funds
vs / and
Defendant / Respondent Intervenor

TO:

, A PAYOR OF FUNDS: You are hereby notified pursuant to Minnesota Statute 518A.57 (2006), that according to

the terms and conditions of the order dated Court, County of the above named obligor , in file number

, and issued by the Judicial District, , is to provide

child support
for the

health care coverage

spousal maintenance

obligee, minor child(ren) of the parties, namely:
Born Born Born

CSD602

State

ENG

4/08

www.mncourts.gov/forms

Page 1 of 2

The relevant provisions of the order are as follows:

STATE OF MINNESOTA COUNTY OF , being first duly sworn upon oath, deposes and says that s/he is the be true.
Dated:
Signature ( Sign only in presence of Notary or Court Deputy)

; that s/he has read the foregoing notice and knows the

contents thereof and that the same is true of his/her knowledge except as to those matters believed to

Sworn / affirmed before me this _________day of ,

Notary Public/ Deputy Court Administrator

CSD602

State

ENG

4/08

www.mncourts.gov/forms

Page 2 of 2