Non-Resident To Serve As Local Counsel Assessment Page 2

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PROOF OF SERVICE
STATE OF MINNESOTA
ss.
COUNTY OF ____________
I, ________________________________________________________, being first duly sworn, depose and state that on
__________________, 20___, I served a true and correct copy of the enclosed document upon all interested parties to this
objection, with postage prepaid, in the United States mail at ____________________, _______________, addressed as follows:
(City)
(State)
SEND ORIGINAL TO:
Compliance Services
Minnesota Department of Labor and Industry
PO Box 64221
St. Paul, MN 55164-0221
SEND COPIES TO:
(Provide Names and Addresses)
Employer (if objection filed by Insurer, or other party):
Other parties (if applicable):
Insurer (if objection filed by Employer, or other party):
Employee (if applicable)
Subscribed and sworn to before me
this ____ day of ________________, 20___.
___________________________________
______________________________________________
Notary Public
Signature

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