JGM301 State ENG Rev 8/18www.mncourts.gov/formsPage 1 of 3Financial Disclosure Form Minn. Stat. 247247 491A.02, subd. 9, 550.011 The purpose of this Financial Disclosure Form is to tell the JUDGMENT CREDITOR what money and property you have which may be used to pay the judgment the creditor obtained against you in the lawsuit. It also allows you to tell the creditor that some or all of your property and money is 223exempt,224 which means that it cannot be taken to pay the judgment. You must answer all questions on this form. If you need more space, continue your answer on the back of the form or attach additional sheets if necessary. If you have questions about this form, you may contact your local court administrator, call the Statewide Self-Help Center at 651-435-6535, or contact an attorney. WARNING: IF YOU CLAIM AN EXEMPTION IN BAD FAITH, OR IF THE JUDGMENT CREDITOR WRONGLY OBJECTS TO AN EXEMPTION IN BAD FAITH, THE COURT MAY ORDER THE PERSON WHO ACTED IN BAD FAITH TO PAY COSTS, ACTUAL DAMAGES, ATTORNEY FEES, AND AN EXTRA $100. 1. JUDGMENT DEBTOR Name2. Individual Partnership Other Corporation 3. Street Address 4. City 5. State 6. Zip 7. Date of Birth 8. If Married, Spouse's Full Name 9. Home Telephone Number 10. Employer or Business 11. Work Telephone Number 12. Street Address 13. City 14. State 15. Zip16. What are your total wages, salary, or commissions per pay period? 17. How often are you paid? Daily Weekly Twice a month Monthly Other 18. Do you have income from any other source? Yes No19. By answering this question, you will be able to claim the exemptions you have for wages and income. The first exemption is already checked for you, check all others that apply: American LegalNet, Inc. www.FormsWorkFlow.com JGM301 State ENG Rev 8/18www.mncourts.gov/formsPage 2 of 3 I claim that 75% of my disposable (after-tax) earnings or 40 times the federal minimum wage ( now$290 for 40-hour week) is exempt (whichever is greater), unless the judgment is for child support. If the Judgment is for child support, I claim that the following percentage of my after-tax earnings is exempt: 50% (I am supporting a spouse and/or dependent child, and the child support judgment is 12 weeks old or less.) 55% (I am supporting a spouse and/or dependent child, and the child support judgment is more than 12 weeks old.) 60% (I am not supporting a spouse and/or dependent child, and the child support judgment is 12 weeks old or less.) 65% (I am not supporting a spouse and/or dependent child, and the child support judgment is more than 12 weeks old.) I am presently receiving or have received relief based on need in the past 6 months so all my wages are exempt.Type of relief you receive: . I have been an inmate in a correctional institution within the past 6 months so all my wages are exempt.Name of institution and release date: . My income is exempt because it is: Unemployment Comp. Worker222s Comp. V.A. Benefits Social Security Accident or Disability Benefits Retirement Benefits Other (Specify)20. Do you have a checking or savings account? (This includes any account whether you have it by yourself or with someone else, or whether it is in your name or any other name) Yes No21. If you claimed an exemption for your wages or income, you may claim an exemption when your money is deposited in a bank. Claim your exemptions by checking the boxes that apply to you: The money in my account is from exempt wages, income, or benefits The money in my account is from the exempt sale of my homestead within the past year. The money in my account is from exempt life insurance received on the death of a spouse or parent. The money in my account is from other exempt property (specify)22. Do you have any stocks, bonds, securities, certificates of deposit, mutual funds, money market account, etc.? (This includes any, whether owned by you alone or with any other person, or whether it is in your name or any other name.) Yes No23. Do you own your home? Yes NoYour homestead (house owned and occupied by you) American LegalNet, Inc. www.FormsWorkFlow.com JGM301 State ENG Rev 8/18www.mncourts.gov/formsPage 3 of 3is exempt up to a value of $390,000 or if used primarily for agricultural purposes, $975,000.Do you own any other houses, land, or real estate? Yes No24. Do you own any motor vehicles, motorcycles, boats, snowmobiles, trailers, etc.? Yes No25. Do you own any of the follow property?Cash or travelers checksHousehold goods, furnishings, and personal effects that are worth more than $10,8000 totalJewelryCoins or stamp collections Firearms/GunsLife insurance policy with a cash (surrender) value more than $9,600InventoryFarm supplies, implements, livestock, grain worth more than $13,000Business equipment, tools, machinery worth more than $11,500 total Accounts receivable/claimsAny property that you are selling on a contract for deedAny other property (specify) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No If you answered yes to any item in question 25, provide the following information:Medical Savings Account not exceeding a present value of $25,000Are you the owner or partner in any business not already listed?Health Savings Account not exceeding a present value of $25,000 Yes No Yes No Description and location of property (if not at residence) Estimated Value Amount Owed (if any) To Whom If you need additional space to answer the questions, continue your answers here. Indicate the question number you are answering. Attach additional sheets if necessary. The above information is true and correct to the best of my knowledge. Dated: Signature/s/ NOTICE: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM TO THE JUDGMENT CREDITOR WITHIN 10 DAYS MAY RESULT IN A CITATION FOR CIVIL CONTEMPT OF COURT. American LegalNet, Inc. www.FormsWorkFlow.com