State of Minnesota County Judicial District: Court File Number: Case Type: District Court Criminal State of Minnesota, Plaintiff vs. PROOF OF SERVICE Defendant STATE OF MINNESOTA COUNTY OF ) ) SS ) (County where Proof of Service is signed) I, that on (name of person who mailed the documents), state (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 . 5 __________________ County Dept. of Corrections (Probation) ________________________________ ________________________________ ________________________________ (Required) _____________________ County Sheriff's Office Attn: Records ________________________________ ________________________________ ________________________________ (Required) ___________________ Police Dept. Attn: Records ________________________________ ________________________________ ________________________________ (check box & use if related to your case) 9 MN Dept. of Human Services Attn: Licensing 444 Lafayette Road N. St. Paul, MN 55155 (check box & use if related to your case) 10 MN Dept. of Health 85 E. 7th Place, #220 P.O. Box 64970 St. Paul, MN 55164-0970 (check box & use if related to your case) 11 MN Dept. of Natural Resources 500 Lafayette Road St. Paul, MN 55155-4040 (check box & use if related to your case) MN Bureau of Criminal Apprehension CJIS-CCH-Court Orders / Petitions 1430 Maryland Avenue East St. Paul, MN 55106 (Required) 2 Office of the MN Attorney General Suite 1800 NCL Towers 445 Minnesota Street St. Paul, MN 55101 (Required) MN Dept. of Corrections Attn: Records 1450 Energy Park Drive, Ste. 200 St. Paul, MN 55108-5219 (Required) 6 3 7 EXP104 State ENG Rev 01/15 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 4 _________________ County Attorney's Office Attn: Criminal Records _________________________________ _________________________________ _________________________________ (Required) 8 ___________________ City Attorney's Office (Prosecutor) Attn: Criminal Division ________________________________ ________________________________ ________________________________ (check box & use if related to your case) 12 MN Department of Public Safety ___________________Division 445 Minnesota Street St. Paul, MN 55101-5155 (check box & use if related to your case) 13 _________________________________ _________________________________ _________________________________ _________________________________ (check box & use if related to your case) 14 ________________________________ ________________________________ ________________________________ ________________________________ (check box & use if related to your case) 15 ______________________________ ______________________________ ______________________________ ______________________________ (check box & use if related to your case) I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116 Date Signature (person who mailed the papers) Printed Name: Address: City/State/Zip: Telephone: EXP104 State ENG Rev 01/15 www.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com