MINNESOTA SECRETARY OF STATE Legal Newspaper Status Application Must be filed between September 1 and December 31, each year Filing Fee: $25.00 Please read the instructions before completing this form. 1. Legal Newspaper Name, Known Office of Issue Address and Phone Number Note: The known office of issue is the principal office maintained by the publisher or managing officer during the newspaper's regular business hours to gather news and sell advertisements and subscriptions, whether or not printing or any other operations of the newspaper are conducted at or from the office, and devoted primarily to business related to the newspaper. Name of Legal Newspaper: (Required)____________________________________________________ Street Address: (Required) _____________________________________________________________ City: (Required) _________________________________State: MN Zip Code: __________________ Phone Number: (Required) _____________________________________________________________ 2. IF CHANGED, List the New Name and/or Address of Known Office of Issue: Name of Newspaper: __________________________________________________________________ Street Address: _______________________________________________________________________ City: __________________________________________ State: MN Zip Code: ___________________ 3. County of Known Office of Issue: (Required) ____________________________________________ 4. This legal newspaper certifies that it has complied with all of the requirements of Minnesota Statutes, section 331A.02. 5. Name, daytime phone number and e-mail address of contact person: ____________________________________________________________________________________ Contact Name Daytime Phone Number E-mail Address 6. I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both capacities. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. __________________________________________________________________________________ Signature of Authorized Representative (Required) LegalNewspaperapplicationRev.7/15/2013 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS This registration is filed by Legal Newspapers to qualify for legal newspaper status. This registration must be filed between September 1 and December 31 of each year if you wish to qualify for legal newspaper status for an entire calendar year. Applications received in our office after January 1, are effective from the date when they are filed and processed by this office. Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Secretary of State. 1. List the name of the legal newspaper, the address of the newspaper's known office of issue and phone number. The known office of issue is the principal office maintained by the publisher or managing officer during the newspaper's regular business hours to gather news and sell advertisements and subscriptions, whether or not printing or any other operations of the newspaper are conducted at or from the office, and devoted primarily to business related to the newspaper. 2. If the Legal Newspaper Name and Address has changed, complete Item 2. 3. List the name of the county in which the known office of issue is located. 4. List a name, daytime phone number and an e-mail address of a person who can be contacted about this form. 5. The application must be signed by a person authorized to act on behalf of the newspaper or by an authorized agent (The signing party must indicate on the document that they are acting as the agent of the person(s) whose signature would be required and that they have been authorized to sign on behalf of that person(s).). To obtain a copy of a form you can go to our web site at www.sos.state.mn.us , or contact us between 9:00am to 4:00pm, Monday through Friday at (651) 296-2803 or toll free 1-877-551-6SOS (6767). Filing Fee: 25.00 Payable to the MN Secretary of State FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Business Services Retirement Systems of Minnesota Building 60 Empire Drive, Suite 100 St Paul, MN 55103 (Staffed 8:00 - 4:00, Monday - Friday, excluding holidays) All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as large print, Braille or audio tape, by calling (651)2962803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the provision of service. American LegalNet, Inc. www.FormsWorkFlow.com