Fill and Sign the Minnesota Notice Intervention 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: Notice of Intervention as a A Party as a Matter of Right            Parent       Legal Custodian             Parent       Legal Custodian To: The Court The Parties or, if represented, their attorneys Pursuant to Rule 23.01 of the Rules of Juvenile Protection Procedure, this is to notify you that I am intervening as a party in the above-referenced Juvenile Protection matter. 1. My name is: First Name Last Name My address is: Street Address Apt. No. City State Zip Code 2. I have a right to intervene in this Juvenile Protection matter because my relationship with the child is as follows (check all that apply and fill in other information) :  I am the child who is the subject of the juvenile protection matter.  I am the parent of the child who is the subject of the juvenile protection matter.  I am the adjudicated father child who is the subject of the juvenile protection matter:  Date of adjudication order  Name of court where adjudication order issued  I am the adoptive parent child who is the subject of the juvenile protection matter.  I am the grandparent of child who is the subject of the juvenile protection and the child lived with me within the two (2) years before the filing of the child protection petition:  Name of your child who is the parent of your grandchild: CHP404 State ENG Rev 3/04-D www.courts.state.mn.us/forms Page 1 of 2  Dates grandchild lived with you:  I am a representative of the Social Services Agency (if not the petitioner). 3. I will automatically become a party to this Juvenile Protection Matter unless within ten (10) days of the date of service of this notice an existing party or the county attorney serves and files a written objection to my intervention challenging the factual basis for my intervention. Upon receipt of a written objection, the court will schedule the matter for hearing and will notify all parties of the date and time of such hearing. Dated: Signature of Person Intervening CHP404 State ENG Rev 3/04-D www.courts.state.mn.us/forms Page 2 of 2