Free State of Minnesota - Minnesota

State of Minnesota County Select County

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



In Re the Marriage of:

Plaintiff / Petitioner vs / and Defendant / Respondent Intervenor STATE OF MINNESOTA ) COUNTY OF ____________________ ) SS
(County where Affidavit Signed)

Affidavit of Facsimile Service

I,
(Name of person who faxed documents)

, state that on
(Date documents faxed)

at ____ o'clock ___.m. at
(Place documents faxed from)

served the attached , by faxing a true and
(Title of documents faxed)

documents, namely correct copy of the document(s) addressed to his/her fax number ( ) , in the city of (Fax number of person to whom documents were faxed) upon (check all that apply): State of Plaintiff / Petitioner (Name) Defendant / Respondent (Name) County Attorney's Office (Name) Other (Name) Dated:

listed below at

Signature ( Sign only in presence of Notary or Court Deputy) Print Name: Subscribed and sworn to before me this day of , Address: City/State/Zip: Telephone: Notary Public/ Deputy Court Administrator

CSX101

State

ENG

Rev 5/08

www.mncourts.gov/forms

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