Notice To County Support And Collections (Dissolution With Children)
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Notice To County Support And Collections (Dissolution With Children) Form. This is a Minnesota form and can be use in District Court Statewide.
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Tags: Notice To County Support And Collections (Dissolution With Children), DIV-813, Minnesota Statewide, District Court
State of Minnesota
District Court
County
Judicial District:
Court File Number:
Case Type:
In the Matter of:
_________________________________
_________________________________
_________________________________
Petitioner’s Name and Address
Notice to County Support
and Collections
vs
_________________________________
_________________________________
_________________________________
Minn. Stat. § 518A.44
Respondent’s Name and Address
To:_____________________________________
(Write your Support and Collections worker’s name)
PRISM No. (if known)
1. You are hereby notified that the Petitioner has commenced the above-entitled action
against the Respondent and that this Notice is given as required by Minnesota Statute § 518A.44.
Petitioner
Respondent
MFIP
is a recipient of or is applying for (check all that apply):
Medical Assistance / MinnesotaCare
Child Care Assistance
IV-E Foster Care
Tribal TANF
2. Petitioner’s birth date is:
.
3. Respondent’s birth date is:
.
4. Petitioner’s and Respondent’s social security numbers are on the attached document:
“Form 11.1: Confidential Information.”
(Note: Attach Form 11.1 only to copy delivered to
Support and Collections. Do not attach Form 11.1 to copy filed in the Court file.)
Signature of Petitioner
(
)
Telephone Number
E-mail address
DIV813
State
ENG
Rev 7/15
www.mncourts.gov/forms
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