WID or SSN

DATE(S) OF CLAIMED INJURY

STATE OF MINNESOTA	}
	} ss.	AFFIDAVIT OF SERVICE
COUNTY OF	}

I,	, being first duly sworn, state that on			, I
served a true and correct copy of the attached		, enclosed in a properly addressed envelope,
by depositing the same, with postage prepaid in the United States mail at			, Minnesota, addressed as follows:

Employee:	Employee Attorney:
Employer:	Employer/Insurer Attorney:
Insurer:	Other Party (Specify):
Other Party (Specify):	Other Party (Specify):

Subscribed and sworn to before me
this	day of	Signature
Notary Public
My Commission expires