HOU302 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 3State of Minnesota District Court County of:Select County Judicial District: Court File Number: Case Type: Housing Plaintiff (Tenant) (first, middle, last) vs. Defendant (Landlord) (first, middle, last) Affidavit of Rent Escrow (Minn. Stat. 247 504B.385) My name is, I understand that I must tell the truth when answering the following questions:1. I am a tenant with the right to live at the property located at the following address: Address: Street Address Apt. or Unit Number City/St./Zip: City State Zip Code County: Phone:2. The name, address, and phone number for the owners(s) of the property are: Name: Address: Street Address Apt. No. City/State/Zip Code Phone:3. The name, address, and phone number for the managers(s) of the property (if different from the owner) are: Name: Address: Street Address Apt. No. City/State/Zip Code Phone:4. The following is a list of all problem(s) or violation(s) regarding my apartment or rental housing: American LegalNet, Inc. www.FormsWorkFlow.com HOU302 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 3 5. I estimate the cost of the repair problems to be (If you have no idea of the estimated cost, you should contact someone to give you a professional estimate.)6. The landlord or manager received the following written notice about the problems or violations with my apartment or rental housing: (Check all that apply) a. On the following date, , the City Inspector issued an order, a copyof which is attached, ordering the landlord or manager to fix the problem or violations by AND: 1. The landlord and manager did not complete the repairs on time OR 2. The City Inspector gave the landlord or manager too much time to complete the repairs, because: b. On the following date, , I mailed or hand delivered to the landlord managera written list of repairs needed or other problems withmy apartment or rental housing. It has been at least 14 days since I provided the landlord and/or manager with the written notice and the landlord and/or manager have not completed the repairs or fixed the problems. I have attached a copy of the list of repairs. 7. My rent is per month due on the of each month. As of this date: (check one) a. My rent is paid in full and no rent is due until: . If this case is not resolved by that date, then on or before that date I will deposit with the court the amount of rent due. b. Rent in the amount of is now due and I am depositing thisamount with the court.8. I ask the court to order one or more of the following (check all that apply): a. Directing the landlord and/or manager to complete the repairs and/or fix the problems with my housing. b. Allowing me to complete the repairs and/or fix the problems with my housing and deduct the costs from my rent. c. Directing that an administrator take over operation of the property to complete the repairs and/or fix the problems with my housing. d. Directing the landlord and/or manager to pay me a rent refund for the month(s) when my housing was not fixed. American LegalNet, Inc. www.FormsWorkFlow.com HOU302 State ENG Rev 7/15www.mncourts.gov/formsPage 3 of 3 e.Directing the landlord and/or manager to give me a rent reduction each month untilthe repairs are completed and problems fixed. f.Directing the landlord and/or manager to pay a fine if this Order is violated. g.Directing the landlord and/or manager to pay reasonable attorney fees. Other: and ordering other relief deemed just and proper by the court.9.Verification and Acknowledgmentsa.I have read this document. To the best of my knowledge, information, and beliefthe information contained in this document is well grounded in fact and iswarranted by existing law.b.I have not been determined by any court in Minnesota or in any other State to be afrivolous litigant and I am not the subject of an Order precluding me from servingor filing this document.c.I am not serving or filing this document for any improper purpose, such as toharass the other party or to cause delay or needless increase in the cost oflitigation or to commit a fraud on the court.d.I understand that if I am not telling the truth or if I am misleading the court or if Iam serving or filing this document for an improper purpose, the court can orderme to pay money to the other party, including the reasonable expenses incurred bythe other party because of the serving or filing of this document, court costs, andreasonable attorney fees. Signature I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116.Dated: County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com