Appendix II: AFFIDAVIT OF PRO BONO REPRESENTATION MINNESOTA STATE BOARD OF CONTINUING LEGAL EDUCATION 180 E. 5th Street, Suite 950, St. Paul, Minnesota 55101 651-297-7100 www.cle.mn.gov clestaff@mbcle.state.mn.us An Affidavit of Pro Bono Representation must be submitted Telephone: Name and address of referring legal services provider: Name and phone number of contact person at legal services provider: Type(s) of Representation Provided: Consumer # of hours of pro bono legal representation: # of CLE credit hours claimed:5 By submitting this form (please check box to confirm): I give permission to the Minnesota Board of Continuing Legal Education to contact the referring legal services provider to verify that the information I have provided is true and accurate; and I understand that the Board may use this information that I have provided six (6) hours of pro 1 Your CLE reporting category is found on your lawyer license card issued by the Lawyer Registration Office and online at . 2 Address changes must be made by sending a written notice to the Lawyer Registration Office, 180 E 5th Street, Suite 950, St. Paul, Minnesota 55101. 3 An email confirmation will be sent after credits are approved or denied. 4 If representation covers more than one reporting period, submit a separate Affidavit of Pro Bono Representation for each reporting period. If representation is ongoing, write 223ongoing224 as the date representation ended. American LegalNet, Inc. www.FormsWorkFlow.com