State of Minnesota County Judicial District: Court File Number: Case Type: , Plaintiff/Petitioner And District Court Notice and Application for Taxation of Costs and Disbursements . Defendant/Respondent To: Name of other party and County Court Administration (Name of County) State of Minnesota County of I, Costs and Disbursements ) ) SS ) submit this application for costs and disbursements: Amount Claimed $ $ $ $ $ $ $ Amount Allowed $ $ $ $ $ $ $ Statutory Costs (Minn. Stat. � 549.02, subd. 1) Court Filing Fee Motion Fees Jury Fee Medical Record Fees Cost of Service Subpoena Fees Experts (specify total amount sought and list in an attachment the name, date of appearance at hearing/trial and a breakdown of claimed expenses for each expert) Reproduction of Exhibits $ $ $ $ Depositions (specify total amount sought and list in an attachment: the name of the deponent, date the deposition was used at hearing/trial - either offered as an exhibit or used to impeach a witness - and specify expenses associated with both the video deposition and the traditional deposition) $ $ CIV116 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Other (specify or attach separate sheet in this form) TOTAL CLAIMED: $ $ $ I, (the attorney for a party in the above-entitled action) (a party in the above-entitled action) state that the above is a true and correct statement of costs incurred and disbursements made and which the above-named party is entitled to recover in this action. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. � 358.116. Signature Attorney's Name / Party's name (use party's name if party not represented by counsel) Address City, State, Zip E-mail address TOTAL ALLOWED: $ This above bill of Costs and Disbursements taxed and allowed as indicated in the right-hand column, above. Date Court Administrator or District Court Judge By District Court Administrator Deputy Administrator CIV116 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Costs and disbursements will be taxed NOTICE TO ATTORNEY FOR ADVERSE PARTY(S): ADVERSE PARTY(S) BEING TAXED: Attorney or Adverse Party's name if no attorney For (Name of Party) Attorney or Adverse Party's name if no attorney For (Name of Party) Attorney or Adverse Party's name if no attorney For (Name of Party) Attorney or Adverse Party's name if no attorney For (Name of Party) pursuant to Rule 54.04 (Rules of Civil Procedure). Objections may be filed Pursuant to Rule 54.04(c). Note: If adverse party is not represented by an attorney, cross out Attorney and print adverse party's name (use additional pages to identify additional parties) State of Minnesota County of I, County of , ) ) ) , of the City of , State of Minnesota, that on the , day of , served the Notice and Application for Taxation of Costs and Disbursements incurred by prevailing party on the person(s) named below by mailing a copy thereof, enclosed in an envelope, postage prepaid, and by depositing the same in the post office at following address(es): Name Address City, State, Zip Name Address City, State, Zip , directed to the attorney / party at the (If more than one party / attorney served, include information on a separate list and attach) I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. � 358.116. Signature of Affiant CIV116 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com