Affidavit Of Service Of Notice To The Commissioner Of Human Services Regarding Possible Claims Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Affidavit Of Service Of Notice To The Commissioner Of Human Services Regarding Possible Claims Form. This is a Minnesota form and can be use in Department Of Commerce Statewide.
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Tags: Affidavit Of Service Of Notice To The Commissioner Of Human Services Regarding Possible Claims, 70.3.4, Minnesota Statewide, Department Of Commerce
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AFFIDAVIT OF SERVICE OF NOTICE TO
THE COMMISSIONER OF HUMAN SERVICES
REGARDING POSSIBLE CLAIMS (UNDER
MINN. STAT. 246.53, 256B.15, 256D.16 OR 261.04)
Minn. Stat. 524.3-801(d)
Minnesota Uniform Conveyancing Blanks
Form 70.3.4 (2011)
State of Minnesota
County of
DISTRICT COURT
PROBATE DIVISION
Judicial District
Court File Number
In Re: Estate of
(Deceased)
AFFIDAVIT OF SERVICE OF NOTICE TO
THE COMMISSIONER OF HUMAN SERVICES REGARDING
POSSIBLE CLAIMS (UNDER MINN. STAT. 246.53, 256B.15,
256D.16 OR 261.04)
State of Minnesota, County of
(“Affiant”),
the personal representative or
being first duly sworn, on oath, states that to my personal knowledge, on
(insert month/day/year of mailing)
the attorney for the personal representative served a Notice, a copy of which is attached, upon the Commissioner of Human Services by
mailing it in a sealed envelope, postage prepaid by depositing the same with the United States Postal Service, addressed to: Commissioner
of Human Services, Attention: Special Recovery Unit/Estate Notice, P.O. Box 64995, St. Paul, Minnesota, 55164-0995.
The real property affected by the Notice is located in
as follows:
County, Minnesota, and is legally described
Check here if all or part of the described real property is Registered (Torrens)
Note: Attach a copy of the Notice to the Commissioner of Human Services Regarding Possible Claims (Form No. 70.3.1)
Page 1 of 2
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Minnesota Uniform Conveyancing Blanks Form 70.3.4
Page 2 of 2
Affiant
(signature)
Signed and sworn to before me on
, by
(month/day/year)
(insert name of Affiant)
.
(Stamp)
(signature of notarial officer)
Title (and Rank):
My commission expires:
(month/day/year)
THIS INSTRUMENT WAS DRAFTED BY:
(insert name and address)
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