Free STATE OF MINNESOTA - Minnesota

M.S. § 524.5-113

State of Minnesota
Select County County of _____________________

District Court Probate Division Judicial District: ___________________ Court File No. ______________________ Case Type: 14, Conservatorship

In Re: Guardianship and Conservatorship of

Affidavit of Service by Mail
_____________________________, Ward and Protected Person ____________________________being first sworn, says that on (date) ___________, 20____, he/she served (name document served) _____________________________________________ _____________________________________________________________________________ on the following persons by mail: 1. Ward/Protected Person: Name:________________________________________________ Address: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ 2. Interested Parties: Relationship Name Address a) Spouse (include an adult with whom Respondent has resided for six months or more):

b) Kindred: (adult children, parents and adult brothers and sisters; if none of these, then list the nearest adult kin; See M.S. § 524.5-303(b)(3) and 524.5-102 subd. 7)

GAC 3-UM State

ENG

Rev 4/04

www.courts.state.mn.us/forms

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M.S. § 524.5-113

c) Administrator (if Respondent is in a hospital, nursing home, home care agency or other institution):

d) Legal Representative (See M.S. § 524.5-102, subd. 8):

e) Persons serving as guardian or conservator:

GAC 3-UM State

ENG

Rev 4/04

www.courts.state.mn.us/forms

Page 2 of 3

M.S. § 524.5-113

f) Other persons:

________________________________________ Signature of Affiant Sworn/affirmed before me this ____________________, 20_____. __________________________________ Notary Public \ Deputy Court Administrator THIS FORM MUST BE COMPLETED AND RETURNED TO THE COURT WITH A COPY OF THE DOCUMENT MAILED TO EACH PERSON

GAC 3-UM State

ENG

Rev 4/04

www.courts.state.mn.us/forms

Page 3 of 3