DISTRICT COURT

STATE OF MINNESOTA

COUNTY OF JUDICIAL DISTRICT

Plaintiff (tenant) RENT ESCROW

Plaintiff states under oath:

1) My address is

2) My landlord’s name is

3) My landlord’s address is

4) The monthly rent is $

5)  I sent the landlord a written notice describing the repair problems or violations of the
lease. The landlord did not fix them within 14 days. A copy of my letter or other written
communication is attached.
and / or
 An inspector ordered the landlord to make repairs. The inspector’s deadline has passed,
and the landlord has not made all the repairs. A copy of the inspector’s orders is
attached.

6) As of today, the amount of rent that I owe is $ I am depositing that amount with
the court.

7) My best estimate is that it would cost $ for the landlord to make all the repairs.

8) The landlord has known about these repair problems since approximately the following
date or dates

9) Since these repair problems have existed, my apartment has not been worth the amount
of rent I pay. It has only been worth $ per month.

10) I respectfully ask the court to issue an order including the following:
a. Order the landlord to make all of the repairs right away.
 b. Reduce my rent to $ per month until the month after all of the repairs are
completed. For any repairs that the landlord does not complete by the Court’s deadline,
authorize me to pay for the repairs myself and deduct the payments from future rent.

c. Of the money I deposited with the court, order that $ be returned to me, for
the rent that I have paid while the landlord did not make the repairs.

d. If I am entitled to more rent money back for the repair problems in the past months,
enter a judgment against the landlord for $ and authorize me to collect
the judgment by taking it out of future months’ rent.

e. If I have used an attorney, enter a judgment in my favor for reasonable attorney fees.
Authorize me to collect the judgment by taking it out of future months’ rent.

f. Set a follow-up hearing to make sure the landlord has made the repairs ordered.

g. Other:

11) To the best of my knowledge, I am not filing this case for an improper reason, such as harassment or
delay; my claims are supported by the law, and there is evidence for them. I know that I can be fined or
sanctioned by the court if this statement is false.

I declare under penalty of perjury that everything I have stated in this document is true and correct.

Dated:
Signature

Name:
Address:
City, State, Zip:
Phone:
E-mail:

For the court to fill out

Total rent deposited: $ _____________ + $16.00 filing fee = $ _________ total paid.

Set for _________________ at __ M, in ______________ Notice sent _________

Continued to ____________ at __ M ,in ______________ Notice sent _________