FORM 139. TAXATION OF COSTS AND DISBURSEMENTS STATE OF MINNESOTA Supreme Court Court of Appeals NOTICE, STATEMENT AND CLAIM OF COSTS AND DISBURSEMENTS INCURRED BY PREVAILING PARTY Prevailing Party: Appellant/Relator CASE TITLE: APPELLATE COURT CASE NUMBER: Respondent COSTS AND DISBURSEMENTS Statutory Costs Clerk of Appellate Courts Filing Fee $ 300.00 Printing Appellant Brief and Addendum $ Printing Respondent Brief Other (specify) $ $ $ Transcript of Case Used for $ Appeal to Appellate Courts Only TOTAL: $ The above bill of Costs and Disbursements taxed and allowed Dated AnnMarie S. O'Neill Clerk of Appellate Courts STATE OF MINNESOTA COUNTY OF Being duly sworn, I the attorney for the prevailing party in the above-entitled action, state that the above is a true and correct statement of costs incurred and disbursements made by the prevailing party in that action. NOTARY STAMP, SIGNATURE AND DATE: Respectfully, Attorney Name Dated Signature Address Signature By Assistant Clerk American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO ATTORNEY FOR ADVERSE PARTY(S): Costs and disbursement will be taxed pursuant to Rule 139.03 (Rules of Civil Appellate Procedure), objections hereto may be filed pursuant to Rule 139.04. ADVERSE PARTY(S) BEING TAXED: Attorney For (Name of Party) For Attorney (Name of Party) Attorney For (Name of Party) For Attorney (Name of Party) Please include supporting documentation for all amounts claimed. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MINNESOTA COUNTY OF ) ) ss. ) I, County of that on the Prevailing Party on the service) following addresses(es): day of , of the City of , , the attorney for , , (s)he , , State of Minnesota, being duly sworn, says Served the Notice, Statement and Claim of Costs and Disbursements Incurred by in this action, by (specify those served and manner of , directed to said attorney at the Name Name Address Address City, State, Zip The last known address(es) of said attorney(s). City, State, Zip Subscribed and sworn to before me this day of , 20 . Notary Public American LegalNet, Inc. www.FormsWorkFlow.com