EXP104StateENG Rev 4/19www.mncourts.gov/formsPage 1 of 2State of Minnesota District Court County of:Select County Court File Number: Judicial District: Case Type: Criminal PROOF OF SERVICEState of Minnesota, Plaintiffvs. Defendant (first, middle, last)I, (name of the person who mailed thedocuments), state that on (date), I served the attached documents, Notice of Hearing and Petition for Expungement and proposed Order, by mailing true and correct copies to the parties checked below at the addresses listed by putting envelopes with sufficient postage in the U.S. Mail in the City of . 1 MN Bureau of Criminal Apprehension 5 County Dept. of 9 MN Dept. of Human Services CJIS-CCH-Court Orders / Petitions Corrections (Probation) ATTN: Licensing, Legal Division 1430 Maryland Avenue East P.O. Box 64242 St. Paul, MN 55106 St. Paul, MN 55164-0242 (Required) (Required) (Check box & use if related to your case) 2 Office of the MN Attorney General 6 County Sheriff's Office 10 MN Dept. of Health Suite 1800 NCL Towers ATTN: Records 85 E. 7th Place, #220445 Minnesota Street P.O. Box 64970 St. Paul, MN 55101 St. Paul, MN 55164-0970 (Required) (Required) (Check box & use if related to your case) 3 MN Dept. of Corrections 7 Police Dept. 11 MN Dept. of Natural Resources ATTN: Records ATTN: Records 500 Lafayette Road 1450 Energy Park Drive, STE. 200 Box # 47 St. Paul, MN 55108-5219 St. Paul, MN 55155-4040 (Required) (Check box & use if related to your case) (Check box & use if related to your case) American LegalNet, Inc. www.FormsWorkFlow.com EXP104StateENG Rev 4/19www.mncourts.gov/formsPage 2 of 2 4 County 8 City 12 MN Department of Public Safety Attorney's Office Attorney's Office (Procecutor) Division ATTN: Criminal Records ATTN: Criminal Division 445 Minnesota Street St. Paul, MN 55101-5155 (Required) (check box & use if related to your case) (check box & use if related to your case) 13 14 15 (check box & use if related to your case) (check box & use if related to your case) (check box & use if related to your case) I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature/s/ County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com