EMPLOYEE SOCIAL SECURITY NUMBER DATE(S) OF CLAIMED INJURY STATE OF MINNESOTA COUNTY OF I, } } } AFFIDAVIT OF SERVICE ss. , being first duly sworn, state that on served a true and correct copy of the attached ,I , enclosed in a properly addressed envelope, by depositing the same, with postage prepaid in the United States mail at Employee: Employee Attorney: Employer: Employer/Insurer Attorney: Insurer: Other Party (Specify): Other Party (Specify): , Minnesota, addressed as follows: Other Party (Specify): Subscribed and sworn to before me this day of Signature Notary Public My Commission expires Affidavit of Service (10/06) American LegalNet, Inc. www.FormsWorkflow.com