Fill and Sign the Certificate Parties Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: , Plaintiff/Petitioner Certificate of Representation and and Parties (Minn. Gen. R. Prac. 104(a)) . Defendant/Respondent Date Case Filed: This Certificate must be filed pursuant to Rule 104(a) of the General Rules of Practice for the District Courts if the case is a family case or a civil case listed in Minn. Gen. R. Prac. 111.01. If information is not then known to the filing party at the time of filing, it shall be provided to the Court Administrator in writing by the filing party within seven (7) days of learning the information. Any party impleading additional parties shall provide the same information to the Court Administrator. The Court Administrator shall, upon receipt of the completed certificate, notify all parties or their lawyers, if represented by counsel, of the date of filing the action and the file number assigned. ATTORNEY FOR PLAINTIFF/PETITIONER ATTORNEY FOR DEFENDANT/ RESPONDENT Name Name Postal Address Postal Address City State Zip Code City State Zip Code ( ) ( ) Telephone Number Telephone Number E-mail address E-mail address Minnesota Attorney License No. Minnesota Attorney License No. CIV102 State ENG Rev 05/13 www.mncourt.gov/forms Page 1 of 2 PLAINTIFF/PETITIONER, Self-represented DEFENDANT/RESPONDENT, Self-represented Name Name Postal Address Postal Address City State Zip Code City State Zip Code ( ) ( ) Telephone Number Telephone Number E-mail address E-mail address (Attach additional sheets for additional attorneys / parties) Note: If either Plaintiff/Petitioner or Defendant/Respondent gets an attorney, the attorney’s name, address, telephone number and attorney ID number must be given in writing to the Court Administrator immediately. CIV102 State ENG Rev 05/13 www.mncourt.gov/forms Page 2 of 2