DIV813 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: In the Matter of: Petitioner's Name and Addressand Respondent's Name and AddressNotice to Public Authority (Minn. Stat. 247 518A.44)To: (Write your case worker's name, if known) IV-D Case No. (if known):1.You are hereby notified that the Petitioner has started the above-entitled action against theRespondent and that this Notice is given as required by Minnesota Statute 247 518A.44. Petitioner Respondentis a recipient of or is applying for (check all that apply): MFIP Medical Assistance/Minnesota Care IV-E Foster Care Child Care Assistance 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 deliveredto the Public Authority. Do not attach Form 11.1 to copy field in the Court file.) Signature of Petitioner Telephone E-mail address American LegalNet, Inc. www.FormsWorkFlow.com