CSX101 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 of Facsimile ServiceI, state that on at (Name of person who faxed documents) (Date documents faxed) o'clock .m. at served the attached documents, namely,(Place documents faxed from) (Title of documents faxed)by faxing a true and correct copy of the document(s) addressed to listed below at his/her fax number in the city of State of upon (check all that apply): Petitioner (Name) Respondent (Name) County Attorney's Office (Name) Other (Name) I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com