Free State of Minnesota - Minnesota

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

District Court

In the Matter of: _________________________________ _________________________________ _________________________________
Petitioner's Name and Address

Notice to County Support and Collections
Minn. Stat. § 518A.44

vs _________________________________ _________________________________ _________________________________
Respondent's Name and Address

To:_____________________________________ (Write your Support and Collections worker's name)

PRISM No. (if known)

1. You are hereby notified that the Petitioner has commenced the above-entitled action against the Respondent and that this Notice is given as required by Minnesota Statute § 518A.44. Petitioner Respondent MFIP is a recipient of or is applying for (check all that apply): IV-E Foster Care

Medical Assistance / MinnesotaCare Tribal TANF

Child Care Assistance 2. Petitioner's birth date is: 3. Respondent's birth date is: "Form 11.1: Confidential Information."

. . (Note: Attach Form 11.1 only to copy delivered to

4. Petitioner's and Respondent's social security numbers are on the attached document:

Support and Collections. Do not attach Form 11.1 to copy filed in the Court file.)

Signature of Petitioner ( ) Telephone Number

DIV813

State

ENG

Rev 1/09-D

www.mncourts.gov/forms

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

District Court

In the Matter of:

Petitioner vs.

Affidavit of Mailing or Delivery of Notice to County Support and Collections

Respondent STATE OF MINNESOTA COUNTY OF I, day, year) , ) ) SS , being sworn, state that on (month, , I (check one) hand-delivered OR delivering a

(County where Affidavit signed)

mailed the Notice of my court action to Support and Collections by (check one) copy to the receptionist of the Support and Collections office located at:

OR by placing in an envelope a true and correct copy addressed to at State of in the City of Zip Code ____________ and depositing the envelope, with

sufficient postage, in the United States Mail at the Post Office located in the City of in the State of Date
Signature of Person Who Mailed or delivered Documents Address: City, State, Zip Code

.

Sworn/affirmed to before me this Day of

,

.

Notary Public/Deputy Court Administrator

DIV813

State

ENG

Rev 1/09-D

www.mncourts.gov/forms

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