CSX1203 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 1State of Minnesota District Court County of:Select County Judicial District: Court File Number: Case Type: Petitioner (first, middle, last)and Respondent (first, middle, last) In Re the Marriage of: Intervenor Affidavit is Support of Motion to Reinstate Driver's License I, , state the following reasons whyan order for reinstating my driver's license(s) should be granted. Check one of the statements below that apply: I have never entered into a written payment agreement and request that the court establish a payment agreement pursuant to Minn. Stat. 247 518A.69. I have signed a written payment agreement but request that the court make changes to the payment agreement by taking into consideration my circumstances described briefly below. Signature I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com