STATE OF MINNESOTA
COUNTY OF RAMSEY

SECOND JUDICIAL DISTRICT
DISTRICT COURT
PROBATE DIVISION
Court File No. ________________________
Estate of 
  ______________________________________________, 
Deceased

AFFIDAVIT OF SERVICE OF NOTICE TO THE COMMISSIONER OF HUMAN SERVICES REGARDING POSSIBLE CLAIMS UNDER MINN. STAT. §§ 246.53, 256B.15, 256D.16 OR 261.04	(reserved for recording data)	

STATE OF MINNESOTA

COUNTY OF ________________________		
ss.	

________________________________________, being first duly sworn, on oath, says that on ____________________ (date), at _____________________, Minnesota (City/State) I served a copy of the attached Notice upon the Commissioner of Human Services by mailing it in a sealed envelope, postage prepaid by depositing the same with the U.S. Postal Service, addressed to the Commissioner of Human Services, Attention:  Special Recovery Unit/Estate Notice, P.O. Box 64995, St. Paul, Minnesota 55164-0095.

The real property affected by the Notice is located in Hennepin County, Minnesota, and is legally described as follows:  ________________________________________________________________________________

  Check if part of all of land is Registered (Torrens)

NOTE:  Attach Notice to Commissioner and redact the Social Security numbers if filing with the County Recorder or Registrar of Titles.

Dated: ________________________________
		___________________________________________
Affiant
	
THIS INSTRUMENT DRAFTED BY:
Attorney for Applicant:
Name:  _______________________________
Firm Name:  ___________________________
Address:  _____________________________	NOTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK):

	
_____________________________________
_____________________________________
Attorney License No.:  __________________
Telephone:  ___________________________
Fax:  _________________________________
Email:  _______________________________
	Subscribed and sworn to before me on ______________ ________________________________________ (date)
by __________________________________________.

_____________________________________________
Signature of Notary Public or Other Official