DIV810 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: Dissolution In Re the Application of: Current Name (First, Middle, Last) For a change of name to: Proposed Name (First, Middle, Last) Felony Notification Affidavit Application for Name Change Application for Marriage License with Name Change Application for Name Change Pursuant to Marriage DissolutionA notice pursuant to Minn. Stat. 247259.13 was served upon the prosecuting authority that obtained the conviction on the and which proof of service has been filed with the court on the . If the prosecuting authority who obtained the conviction is from another state other than Minnesota or federal jurisdiction a notice was served also on the Minnesota Attorney General at 102 State Captiol Building, St. Paul, MN 55155 and which proof of service has been filed with the court on the .In reference to the above period of 30 days has passed since notifying the prosecuting authority. A person who knowingly violates Minnesota Stat. 259.13 is guilty of a gross misdemeanor.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