HAR501 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 2State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Harassment Petitioner (first, middle, last)vs. Respondent (first, middle, last)Affidavit and Order to Show Cause for Contempt (Harassment) (Minn. Stat. 247609.748, subd. 6(i))I, Petitioner Police Officer Sheriff's Deputy Other interested person named by the Court state that Respondent has violated the following provisions of the Order dated.(List the parts of the Order that Respondent violated:) The order was violated when Respondent committed the following acts (Describe specific acts, including what happened, who was involved, and give the approximate date. List most recent dates first. Add additional sheets, if necessary): I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Signature Dated: County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address:Distribution Certified copy or original-Return to Court Administrator with Affidavit of Service attached Copy for file until original returned Copy for Petitioner(s) Copy for local police department Copy for Respondent(s) Copy for Sheriff Other: OrderTo: , Respondent American LegalNet, Inc. www.FormsWorkFlow.com HAR501 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 2Based on the Affidavit and other information in the court file in this matter, YOU ARE ORDERED to appear at on at (time) .m.and explain why you should not be found in Contempt of Court for violating the Order dated.It is further ordered that the appropriate police or sheriff's department shall help Petitioner serve this Order, without charge. NOTE: Any response by you shall be in writing and served and filed with the Court Administrator's Office at least five days before the scheduled hearing. The Court may disregard any response served or filed with the Court less than five days before such hearing in deciding the contempt matter in question. NOTE: Bring witnesses and supporting documentation to the hearing. You may not be able to use written reports, affidavits, or statements from persons who are not at the hearing as witnesses. If you do not appear, the Court may find you in contempt of court, any may issue a warrant for your arrest. Dated: Judge of District Court American LegalNet, Inc. www.FormsWorkFlow.com