Minnesota > Statewide > District Court > Dissolution
Notice To County Support And Collections (Dissolution With Children) DIV-813 - Minnesota
| Notice To County Support And Collections (Dissolution With Children) Form. This is a Minnesota form and can be used in Dissolution District Court Statewide . |
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State of Minnesota County Judicial District: Court File Number: Case Type: District Court Dissolution with Children In the Matter of: _________________________________ _________________________________ _________________________________ Petitioner's Name and Address Vs. _________________________________ _________________________________ _________________________________ Respondent's Name and Address Notice to County Support and Collections Minn. Stat. §518.551, subd. 5 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 § 518.551. Petitioner apply): MFIP Medical Assistance Child Care Assistance 2. Petitioner's birth date is: 3. Respondent's birth date is: IV-E Foster Care MinnesotaCare . . Tribal TANF Respondent is a recipient of or is applying for (check all that 4. Petitioner's and Respondent's social security numbers are on the attached document:"Form 11: Confidential Information." (Note: Attach Form 11 only to copy delivered to Support and Collections. Do not attach Form 11 to copy filed in the Court file.) Signature of Petitioner ( ) Telephone Number DIV813 State ENG Rev 2/03-D www.courts.state.mn.us/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com State of Minnesota County Judicial District: Court File Number: Case Type: District Court Dissolution with Children In the Matter of: Petitioner vs. Respondent STATE OF MINNESOTA ) COUNTY OF ) SS (County where Affidavit signed) I, (month, day, year) delivered OR (check one) located at: by placing in an envelope a true and correct copy addressed to at State of in the City of Zip Code ____________ and depositing mailed , Affidavit of Mailing or Delivery of Notice to County Support andCollections , being sworn, state that on , I (check one) hand- the Notice of my court action to Support and Collections by delivering a copy to the receptionist of the Support and Collections office OR the envelope, with sufficient postage, in the United States Mail at the Post Office located in the City of in the State of . Signature of Person Who Mailed or delivered Documents (Sign only in presence of Notary Public) Note: Petitioner may mail or deliver the Notice to Support and Collections him/herself Date: Month Day Year Address: City & State: Telephone: ( ) (of person who mailed documents) Sworn/affirmed to before me this Day of , . Notary Public/Deputy Court Administrator DIV813 State ENG Rev 2/03-D www.courts.state.mn.us/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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