CSD602 State ENG Rev 8/14www.mncourts.gov/formsPage 1 of 1State of Minnesota District Court Select County Judicial District: Court File Number: Case Type: In Re the Marriage of: Petitioner (first, middle, last) Respondent (first, middle, last) Intervenor TO: , A PAYOR OF FUNDS: and conditions of the order dated , and issued by the District Court, County of , in file numberthe above named obligor is to provide child support health care coverage spousal maintenance for the obligee, and/or minor children of the parties namely: Born Born Born I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247358.116. Signature Dated: County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com