Fill and Sign the Affidavit Service Motion Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Juvenile In the Matter of the Welfare of the Child(ren) of: Affidavit of Service: Notice of Motion and Motion to Intervene Parent  Legal Custodian  Parent  Legal Custodian I, , state that on , I served the (Name of person who mailed or hand delivered documents) (Date service made) Notice of Motion and Motion to Intervene by (check one) : Hand-delivering the document; OR Mailing the document to the following person(s) at the following addresses: 1. First Middle Last Street Address Apt. No. City County State and Zip 2. First Middle Last Street Address Apt. No. City County State and Zip 3. First Middle Last Street Address Apt. No. City County State and Zip 4. First Middle Last CHP406 State ENG Rev 11/18 www.mncourts.gov/forms Page 1 of 2 Street Address Apt. No. City County State and Zip 5. First Middle Last Street Address Apt. No. City County State and Zip 6. First Middle Last Street Address Apt. No. City County State and Zip 7. First Middle Last Street Address Apt. No. City County State and Zip 8. First Middle Last Street Address Apt. No. City County State and Zip I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116 Dated Signature Name: Address: County and state where signed City/State/Zip: Telephone: Email: CHP406 State ENG Rev 11/18 www.mncourts.gov/forms Page 2 of 2