State of Minnesota County of _____________________ District Court Probate Division Judicial District: ___________________ Court File No. ______________________ Case Type: 14, Conservatorship In Re: Guardianship and Conservatorship of Affidavit of Service by Mail _____________________________, Ward and Protected Person State of Minnesota County of ) ) SS ) ____________________________, says that on (date) , 20____, he/she served (name document served) _____________________________________________ _____________________________________________________________________________ on the following persons by mail: 1. Ward/Protected Person: Name:________________________________________________ Address: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ 2. Interested Parties: Relationship Name Address a) Spouse (include an adult with whom Respondent has resided for six months or more): b) Kindred: (adult children, parents and adult brothers and sisters; if none of these, then list the nearest adult kin; See M.S. § 524.5-303(b)(3) and 524.5-102 subd. 7) GAC 3-UM State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com c) Administrator (if Respondent is in a hospital, nursing home, home care agency or other institution): d) Legal Representative (See M.S. § 524.5-102, subd. 8): e) Persons serving as guardian or conservator: GAC 3-UM State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com f) Other persons: 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 THIS FORM MUST BE COMPLETED AND RETURNED TO THE COURT WITH A COPY OF THE DOCUMENT MAILED TO EACH PERSON GAC 3-UM State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com