DIV816 State ENG Rev 5/17www.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)vs Respondent (first, middle, last)Affidavit of Service to Public AuthorityMy name is . On (month, day, year), , I hand-delivered OR mailed the Noticeof my court action to the Public Authority by (check one): OR delivering a copy to the receptionist of the Public Authority's office at OR by placing in an envelope a true and correct copy addressed to Name: Address: City, State, Zip:and depositing the envelope, with sufficient postage, in the United States Mail at the Post Office located in the City of in the State of.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