Fill and Sign the Minnesota Notice County Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: In the Matter of: _________________________________ _________________________________ _________________________________ Petitioner’s Name and Address Notice to County Support and Collections vs Minn. Stat. § 518A.44 _________________________________ _________________________________ _________________________________ Respondent’s Name and Address To:_____________________________________ PRISM No. (if known) (Write your Support and Collections worker’s name) 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 is a recipient of or is applying for ( check all that apply ): MFIP Medical Assistance / MinnesotaCare IV-E Foster Care Child Care Assistance Tribal TANF 2. Petitioner’s birth date is: . 3. Respondent’s birth date is: . 4. Petitioner’s and Respondent’s social security numbers are on the attached document: “Form 11.1: Confidential Information.” (Note: Attach Form 11.1 only to copy delivered to Support and Collections. Do not attach Form 11.1 to copy filed in the Court file.) Signature of Petitioner ( ) Telephone Number E-mail address DIV813 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 1