(Top 3 inches reserved for recording data) AFFIDAVIT OF SERVICE OF NOTICE TO THE COMMISSIONER OF HUMAN SERVICES REGARDING POSSIBLE CLAIMS (UNDER MINN. STAT. 246.53, 256B.15, 256D.16 OR 261.04) Minn. Stat. 524.3-801(d) State of Minnesota County of Minnesota Uniform Conveyancing Blanks Form 70.3.4 (2011) DISTRICT COURT PROBATE DIVISION Judicial District Court File Number In Re: Estate of (Deceased) AFFIDAVIT OF SERVICE OF NOTICE TO THE COMMISSIONER OF HUMAN SERVICES REGARDING POSSIBLE CLAIMS (UNDER MINN. STAT. 246.53, 256B.15, 256D.16 OR 261.04) State of Minnesota, County of ("Affiant"), the personal representative or (insert month/day/year of mailing) being first duly sworn, on oath, states that to my personal knowledge, on the attorney for the personal representative served a Notice, a copy of which is attached, upon the Commissioner of Human Services by mailing it in a sealed envelope, postage prepaid by depositing the same with the United States Postal Service, addressed to: Commissioner of Human Services, Attention: Special Recovery Unit/Estate Notice, P.O. Box 64995, St. Paul, Minnesota, 55164-0995. The real property affected by the Notice is located in as follows: County, Minnesota, and is legally described Check here if all or part of the described real property is Registered (Torrens) Note: Attach a copy of the Notice to the Commissioner of Human Services Regarding Possible Claims (Form No. 70.3.1) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 70.3.4 Affiant (signature) Signed and sworn to before me on (month/day/year) , by (insert name of Affiant) . (Stamp) (signature of notarial officer) Title (and Rank): My commission expires: (month/day/year) THIS INSTRUMENT WAS DRAFTED BY: (insert name and address) American LegalNet, Inc. www.FormsWorkFlow.com