Free State of Minnesota - Minnesota

State of Minnesota
County Judicial District: Court File Number: Case Type:

District Court
Other Civil

______________________________, Petitioner vs. Commissioner of Public Safety, Respondent

Affidavit of Service

STATE OF MINNESOTA COUNTY OF
(County where Affidavit signed)

) ) SS )

I,
(Name of person who mailed documents)

, being sworn, state that I am at least , and that on , I served the attached documents: Petition for Court

18 years of age having been born on
(Date)

Hearing for Reinstatement of Driver's License upon the Commissioner of Public Safety, the respondent in this action, by mailing a true and correct copy of the documents by first class U.S. mail addressed as follows: Minnesota Attorney General Commissioner of Public Safety 445 Minnesota Street, Suite 1800 St. Paul, MN 55101 Dated: Signature of Petitioner, pro se
public or court administrator.) (Sign only in front of notary

Name: Sworn/affirmed before me this day of , Address City/State/Zip: Telephone: (
Notary Public \ Deputy Court Administrator

)

CIV112

State

Eng

4/09

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