STATE OF MINNESOTA
IN COURT OF APPEALS
CASE TITLE:
,
COURT OF APPEALS #
Relator (your name)
vs.
RELATOR’S CERTIFICATE
OF SERVICE BY MAIL OF
1)
,
THE PETITION, UNSIGNED WRIT,
Respondent (employer’s name),
STATEMENT OF THE CASE, AND
UNEMPLOYMENT LAW JUDGE’S
2) Department of Employment & Economic
DECISION
Development,
Respondent
STATE OF MINNESOTA
COUNTY OF
I,
(Name), certify that on
(Date),
I served the attached (1) petition for a writ of certiorari; (2) unsigned writ of certiorari;
(3) statement of the case; and (4) ULJ’s decision from which appeal is taken, on the following
parties by mailing to each of them a copy thereof, enclosed in an envelope, first-class postage
pre-paid, and by depositing the same in the United States Mail, directed to said party as follows:
(Fill in the name and address of the employer or employer’s attorney on the lines below.
Then check the box next to each party to whom documents were mailed.)
Department of Employment & Economic Development
E-200 First National Bank Building
332 Minnesota Street
St. Paul, MN 55101
I declare under the penalty of perjury that everything I have stated in this document is true and
correct.
(Signature)
(County where certificate was signed)
(Date of signature)
(State where certificate was signed)