State of Minnesota District Court County Judicial District: Court File Number: Case Type: Other Civil ______________________________, Petitioner vs. Affidavit of Service Commissioner of Public Safety, Respondent STATE OF MINNESOTA ) ) SS ) COUNTY OF (County where Affidavit signed) I, , being sworn, state that I am at least (Name of person who mailed documents) 18 years of age having been born on , and that on , I served the attached documents: Petition for Court (Date) Hearing for Reinstatement of Driver’s License upon the Commissioner of Public Safety, the respondent in this action, by mailing a true and correct copy of the documents by first class U.S. mail addressed as follows: Minnesota Attorney General Commissioner of Public Safety 445 Minnesota Street, Suite 1800 St. Paul, MN 55101 Dated: Signature (Sign only in front of notary public or court administrator) Name: Sworn/affirmed before me this day of Address , City/State/Zip: Telephone: ( ) Notary Public \ Deputy Court Administrator CIV112 State Eng 7/09 www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com