Supreme Court Court of Appeals STATE OF MINNESOTA Case Title: Appellate Court Case Number: Notice, Statement and Claim of Costs and Disbursements Incurred by Prevailing Party Prevailing Party: Appellant Respondent Relator COSTS AND DISBURSEMENTS Statutory Costs……………$300.00 Print Appellant’s Brief and Appendix…..$_______ Clerk of the Appellate Courts Filing Fee………….$________ Postage………………………………….$_______ Transcript of Case used for appeal To Appellate Courts only…$________ Premium on appeal bond………………$_______ Printing of Respondent’s Brief……………………….$________ Other……………………………………$_______ This above bill of Costs and Disbursements taxed and allowed________________________ Dated Fredrick K. Grittner Clerk of the Appellate Courts By Assistant Clerk STATE OF MINNESOTA COUNTY OF_________________________ Being duly sworn, I the attorney for the prevailing party in the above-entitled action, state that the above is a true and correct statement of costs incurred and disbursements made by the prevailing part in that action. Respectfully, Notary Stamp, Signature and Date: __________________________________ Dated Signature ____________________________________ Attorney’s Name ____________________________________ Address ____________________________________ Signature American LegalNet, Inc. www.FormsWorkflow.com NOTICE TO ATTORNEY FOR ADVERSE PARTY(S): ADVERSE PARTY(S) BEING TAXED: Costs and disbursement will be taxed pursuant to Rule 139.03 (Rules of Civil Appellate Procedure), objections hereto may be filed pursuant to Rule 139.04. __________________________________ Attorney _______________________________ Attorney For _______________________________ (Name of Party) For ____________________________ (Name of Party) __________________________________ Attorney _______________________________ Attorney For _______________________________ (Name of Party) For ____________________________ (Name of Party) American LegalNet, Inc. www.FormsWorkflow.com STATE OF MINNESOTA COUNTY OF _______________ ) ) ss. ) I, ___________________________________, of the City of __________________, County of ____________________, State of Minnesota, being duly sworn, says that on the ________ day of ______________________, ________, (s)he served the Notice, Statement and Claim of Costs and Disbursements Incurred by Prevailing Party on ____________________________, the attorney for __________________________, the _________________________ in this action, by mailing to him/her a copy thereof, enclosed in an envelop, postage prepaid, and by depositing the same in the post office at ____________________________, directed to said attorney at the following address(es): ___________________________________ Name ____________________________________ Name ___________________________________ Address ____________________________________ Address ___________________________________ City, State, Zip ____________________________________ City, State, Zip The last known address(es) of said attorney(s). ___________________________________ Subscribed and sworn to before me this _____ day of ______________________, 20______. ______________________________________ Notary Public American LegalNet, Inc. www.FormsWorkflow.com