Fill and Sign the Minnesota Escrow Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Housing Plaintiff (Tenant) Affidavit of Rent Escrow vs. ( Minn. Stat. §504B.385) Defendant (Landlord) My name is . I understand that I am under oath/affirmation and that in answering the following questions I must tell the truth. 1. I am the 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 County: Phone: ( ) 2. The name, address, and phone number for the landlord(s) of the property are: Name: Address: Street Address Apt. or Unit Number City State Zip Code Phone: ( ) 3. The name, address and phone number for the manager(s) of the property (if different from the landlord) are: Name: Address: Street Address Apt. or Unit Number City State Zip Code Phone: ( ) 4. The following is a list of all problem(s) or violation(s) regarding my apartment or rental housing: 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.) HOU302 State ENG Rev 9/01 www.courts.state.mn.us/forms Page 1 of 3 Last Revised: 9/2001 6. The landlord(s) or manager(s) 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 copy of which is attached, ordering the landlord(s) or manager(s) to fix the problems or violations by AND : (Date)  1. The landlord(s) and manager(s) did not complete the repairs on time. OR  2. The City Inspector gave the landlord(s) or manager(s) too much time to complete repairs, because:  b. On the following date, , I mailed or hand delivered to the  landlord(s)  manager(s) a written list of repairs needed or other problems with my apartment or rental housing. The landlord(s) and/or manager(s) did not complete the repairs or fix the problems within 14 days after I mailed or hand delivered the list of repairs. I have attached a copy of the list of repairs. 7. My rent is $ per month and 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 this amount with the court. 8. I ask the court to order one or more of the following (check all that apply):  a. Directing the landlord(s) and/or manager(s) 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(s) and/or manager(s) to pay me a rent refund for the month(s) when my housing was not fixed.  e. Directing the landlord(s) and/or manager(s) to give me a rent reduction each month until the repairs are completed and problems fixed.  f. Directing the landlord(s) and/or manager(s) to pay a fine if this Order is violated.  g. Directing the landlord(s) and/or manager(s) to pay reasonable attorney fees.  h. Other: and ordering other relief deemed just and proper by the court. 9. Verification and Acknowledgements: HOU302 State ENG Rev 9/01 www.courts.state.mn.us/forms Page 2 of 3 Last Revised: 9/2001 a. I have read this document. To the best of my knowledge, information, and belief the information contained in this document is well-grounded in fact and is warranted by existing law. b. I have not been determined by any court in Minnesota or in any other state to be a frivolous litigant and I am not the subject of an Order precluding me from serving or filing this document. c. I am not serving or filing this document for any improper purpose, such as to harass the other party or to cause delay or needless increase in the cost of litigation 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 I am serving or filing this document for an improper purpose, the court can order me to pay money to the other party, including the reasonable expenses incurred by the other party because of the serving or filing this document, court costs, and reasonable attorney fees. Dated : Signature (Sign only in front of notary public or court administrator.) Name: Sworn/affirmed before me this Address: day of , . City/State/Zip: Telephone: ( ) Notary Public \ Deputy Court Administrator HOU302 State ENG Rev 9/01 www.courts.state.mn.us/forms Page 3 of 3 Last Revised: 9/2001