Free STATE OF MINNESOTA - Minnesota

State of Minnesota
County
Select County
In the Matter of:

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

Petitioner

vs.

Affidavit of Personal Service by Peace Officer/Corrections Officer (Domestic Abuse) (Minn. Stat. § 518B.01, subd. 8)

Respondent

STATE OF MINNESOTA COUNTY OF
(County where Affidavit signed)

) ) ss. )

I, _______________________________ being first sworn/affirmed under oath state that I am a: Peace officer licensed by the state of Minnesota, or Corrections officer, including but not limited to probation officer, court services officer, parole officer or a jail or correctional facility employee. On
(Month, Day, Year Hand-delivered)

, I personally served true and correct copies of the following:

(Place an X in the box next to the documents that you served.) Affidavit of
(Name of person who signed Affidavit)

Petition for Order for Protection Notice of Hearing Ex parte Order for Protection Other:
(Title of any other documents served)

upon
(Name of Respondent)

, in the above-entitled matter at:

Street Address:
(Include name of the facility if appropriate.)

City & State: Dated:
Signature (Sign only in front of notary public or court administrator.)

Name: Subscribed and sworn to before me this day of , . Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator OFP502 State ENG Rev 8/08 www.mncourts.gov/forms Page 1 of 1