STATE OF SOUTH DAKOTA ) IN CIRCUIT COURT )SS: COUNTY OF _______________ ) ____________ JUDICIAL CIRCUIT ****************************************************************************** In the Matter of the Petition of ) ) CIV.___________ _______________________________ ) (Birth Certificate Name), A Minor Child. ) ) For a Change of Name to ) AFFIDAVIT OF SERVICE ) _______________________________ ) (Proposed Name) ) ****************************************************************************** I, _______________________________________, being sworn, state that on the (Name of person who mailed documents) ______ day of __________________________, 20______, I served the following papers: ________________________________________________________________________ (List all papers mailed to the other party; i.e. certified copy of Order for Name Change of A Minor Child and copy of Notice of Entry of Order for Name Change of A Minor Child) by placing true copies of the documents in an envelope addressed to: _________________________________ at ____________________________________ (Name of other parent) (Other parent's mailing address) in the City of _____________________________, State of _______________________, Zip Code ___________ and depositing the envelope, with sufficient postage, in the United States Mail at _________________________________. (City and State mailed from) Dated this _______ day of ______________________, 20_____. ____________________________________ Signature of Person Who Mailed Documents (Sign only in front of a notary or Clerk of Court) Sworn/affirmed before me this _______ day of ____________, 20___. _______________________________ (Notary Public/Clerk of Court) Name: (Printed)_______________________ Address:____________________________ City/State/Zip:________________________ Telephone: (____)_____________________ Page 1 of 1 UJS-036 Affidavit of Service Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com _______________________________ If notary, my commission expires (SEAL)