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