______________________________________________ states upon oath:

            1.         I am the tenant living at ______________________________________________.

            2.         The name and address for the owner(s) of the property is/are _________________

______________________________________________________________________________.

            3.         The name and address for the manager(s) of the property is/are _______________

_____________________________________________________________________________.

            4.         The owner(s) or manager(s) received the following notice about problems with my housing:

                        a.         □          On ___________________, the City Inspector ordered the owner(s) and/or manager(s) to repair the property by __________________. I have attached a copy of the order.

                                    I.         □          The owner(s) and/or manager(s) did not complete the repairs on time, or

                                    ii.        □          The city inspector gave the owner(s) or manager(s) too much time to complete repairs, because _____________________

                                                            _______________________________________________,

                                                            and/or

                        b.         □          On ______________________, I sent or gave a written list of repair needed or other problems with my housing. The owner(s) and/or manager(s) did not complete repairs or correct the problems within 14 days after I sent or gave the list.

            5.         I think it will cost to $ __________ to repair or correct these problems.

            6.         Rent: My monthly rent is $ __________.

                        a.         □          The total rent that I have not paid is $ . I am paying this amount into court.

                        b.         □          I have paid all of my rent to the owner(s) and/or managers.

Optional

            7.         □          Defendant(s) substantially violated my privacy. Minn. Stat. § 504B.211 (formerly § 504.183). Complete all that apply.

                        a.         □          Defendant(s) violated my privacy rights on the following dates:

                                                _____________________________________________________

                                                _____________________________________________________.

                        b.         □          Defendant(s) did not have a reasonable business purpose for entering the property: _______________________________________

                                                _____________________________________________________.

                        c.         □          Defendant(s) did not make a good faith effort to give me reasonable notice under the circumstances before entering the property:

                                                _____________________________________________________

                                                _____________________________________________________.

                        d.         □          Immediate entry onto the property was not necessary: __________

                                                _____________________________________________________.

                        e.         □          Defendant(s) entered the property without prior notice and when I was not present, and did not give me written notice of the entry afterwards.

            8.         □          Defendant(s) failed to pay for utility services for which Defendant(s) were obligated to pay. Minn. Stat. § 504B.215 (formerly § 504.185): __________________________

_____________________________________________________________________________.

            9.         □          Defendant(s) unlawfully terminated utility service. Minn. Stat. § 504B.221 (formerly § 504.26): _________________________________________________________

_____________________________________________________________________________.

            10.       □          Defendant(s) illegally used a shared meter which does not accurately reflect my utility use. Minn. Stat. § 504B.215 (formerly § 504.185), § 504B.221 (formerly § 504.26):

______________________________________________________________________________.

            11.       □          My city code requires landlords to have a rental license. My landlord does/did not have a license and cannot collect rent for the period where the landlord did not have a license. Beaumia v. Eisenbraun, No. A06-1482, 2007 WL 2472298 (Minn. Ct. App. Sep. 4, 2007) (unpublished, attached).

            12.       □          Defendant(s) rented condemned property. Minn. Stat. § 504B.204 (formerly § 504.245): ____________________________________________________________

_____________________________________________________________________________.

            13.       □          Defendant(s) have engaged in harassment by using repeated, intrusive, or unwanted acts, words, or gestures intended to adversely affect the safety, security, or privacy of me, my household members or guests. Minn. Stat. § 609.748: ______________________________

______________________________________________________________________________.

            14.       □           Defendant’s notice for me to move was retaliatory under Minn. Stat. § 504B.285 (formerly § 566.03), § 504B.441 (formerly § 566.28), and was intended in whole or part as a penalty:

                        a          □          for my good faith attempt on _____________ to secure or enforce rights under a lease or contract, oral or written, under the laws of the state or any of its governmental subdivisions, or of the United States; or

                        b          □          for my good faith report on ______________ to a governmental authority of the plaintiff's violation of a health, safety, housing, or building code or ordinance.

            15.       □          Defendant(s) unlawfully ousted or excluded Plaintiff(s) from the premises. Minn. Stat. §§ 504B.231(formerly § 504.255), 557.08, 557.09: __________________________

______________________________________________________________________________.

            16.       □          Defendant(s) unlawfully allowed illegal drug activity on the property, allowed prostitution or related activity to occur on the property, or allowed unlawful use or possession of a firearm on the property. Minn. Stat. § 504B.171 (formerly § 504.181): ___________________

______________________________________________________________________________.

            17.       □          Defendant(s) penalized me for seeking police or emergency assistance. Minn. Stat. § 504B.205 (formerly § 504.215).

                        a.         □          Defendant(s) barred or limited my right to call for police or emergency assistance in response to domestic abuse or other conduct:

                                                ______________________________________________________.

                        b.         □          Defendant(s) penalized me for calling for police or emergency assistance in response to domestic abuse or other conduct: _______

                                                ______________________________________________________.

                        c.         □          Defendant(s) required me to waive my right to call for police or emergency assistance: ____________________________________.

            18.       □          I have a disability. Defendant(s) did not reasonably accommodate my disability. 42 U.S.C. § 3604(f)(3); 24 C.F.R. Part 100; Minn. Stat. § 363.03, subd. 2-2a.:

______________________________________________________________________________.

            19.       □          Defendant(s) committed consumer fraud. Minn. Stat. §§ 325F.68- 325F.70, 8.31, and deceptive trade practices. Minn. Stat. §§ 325D.43-325D.48: ___________________

______________________________________________________________________________.

            20.       □          Other: ______________________________________________________.

Relief

            The purpose of this affidavit and the deposit of rent is to cause the court to schedule a hearing of the facts relating to this cause of action and order the following relief:

            1.         □          Repairs:

                        a.         □          Defendant(s) shall complete repairs and/or correct the problems with my housing.

                        b.         □          If Defendant(s) does/do not complete repairs as ordered by the court,

                                    i.         □          I may complete repairs and/or correct the problems and deduct my costs from the rent.

                                    ii.        □          An administrator may take over operation of the property to complete repairs and/or correct the problems.

                                    iii.       □          A fine for Defendant(s) under Minn. Stat. § 504B.391 of $250 for the first violation, $500 for the second violation, and $750 for the third violation and subsequent violations.

            2.         □          Relocation:

                        a.         If I must leave while repairs are completed or because repairs are not completed, Defendant(s) shall relocate me in an apartment/hotel/motel until the emergency is resolved, and that Defendant(s) prepay the charge for the hotel/motel.

                        b.         Defendant(s) shall pay me relocation costs in the amount of $ __________ for _________________________________________________________.

            3.         □          Harassment. Minn. Stat. § 609.748. Issue a temporary and permanent restraining order:

                        a.         □          Ordering the Defendant(s) to cease or avoid the harassment me, my household members or guests.

                        b.         □          Ordering the Defendant(s) to have no contact with me, my household members or guests.

                        c.         □          Notifying Defendant(s) that violation of the order is a misdemeanor punishable by imprisonment for up to 90 days or a fine up to $700.00 or both, and that a peace officer must arrest without warrant and take into custody a person if the peace officer has probable cause to believe the person has violated a restraining order.

            4.         □          Tenant Privacy, Minn. Stat. § 504B.211 (formerly § 504.183): Award the following:

                        a.         □          Rent abatement in the amount of $ __________ for the months of

                                                ______________________________________________________. b.□Full rescission of the lease.

                        c.         □          Recovery of any damage deposit less amounts retained under the damage deposit statute, Minn. Stat. § 504B.178.

                        d.         □          Up to a $100.00 civil penalty payable to me for each violation, for a total of $ __________.

            5.         □          Retaliation. Minn. Stat. § 504B.285 (formerly § 566.03), § 504B.441 (formerly § 566.28):

                        a.         □          Defendant(s) may not evict me to retaliate against me for complaints I made.

                        b.         □          The notice to vacate is retaliatory and illegal and therefore void.

            6.         □          Illegal activity: Defendant(s) shall take the following action to prevent illegal drug activity, prostitution or related activity, or unlawful use or possession of a firearm on the property. Minn. Stat. § 504B.171 (formerly § 504.181): _______________________________

______________________________________________________________________________.

            7.         □          Defendant(s) shall reasonably accommodate my disability. 42 U.S.C. § 3604-(f)(3); 24 C.F.R. Part 100, Minn. Stat. § 363.03, subd. 2-2a: ____________________________

_____________________________________________________________________________.

            8.         □          Plaintiff shall cease committing consumer fraud and deceptive trade practices, in violation of Minn. Stat. §§ 325F.68-325F.70, 8.31, 325D.43-325D.48. See Love v. Amsler, 441 N.W.2d 555, 557-59 (Minn. Ct. App. 1989).

            9.         □          Rent abatement:

                        a.         □          Retroactive (past) rent abatement:

                                    I.         □          For habitability violations under Minn. Stat. § 504B. 161 (formerly § 504.18) for $ _________ per month for the months of _____________________________________.

                                    ii.        □          For condemned property under Minn. Stat. § 504B.204 (formerly § 504.245) for $ _________ per month for the months of _____________________________________.

                                    iii.       □          For unlicensed property under Beaumia v. Eisenbraun, No. A06-1482, 2007 WL 2472298 (Minn. Ct. App. Sep. 4, 2007) (unpublished, attached). for $ _________ per month for the months of _________________________________.

                                    iv.       □          For privacy violations under Minn. Stat. § 504B.211 (formerly § 504.183) for $ _________ per month for the months of ___________________________________________.

                        b.         □          Prospective (future) rent abatement in the amount of $ __________ per month until the violations are remedied.

            10.       □          Other damages:

                        a.         □          $ __________ for consequential damages arising directly out of the failure of Defendant(s) to make repairs and maintain the premises according to health and housing codes, for ___________________

                                                _____________________________________________________.

                        b.         □          $ __________ for the failure of Defendant(s) to pay for utility services for which Defendant(s) were obligated to pay. Minn. Stat. § 504B.215 (formerly § 504.185).

                        c.         □          $ 500.00 or __________ (3 times $ __________) for Defendant(s) unlawfully terminating utility service. Minn. Stat. § 504B.221.

                        d.         □          $ 500.00 or __________ (3 times $ __________) for Defendant(s) illegal use of a shared meter which does not accurately reflect my utility use. Minn. Stat. § 504B.215 (formerly § 504.185), § 504B.221 (formerly § 504.26).

                        e.         □          $ 500.00 or __________ (3 times $ __________) for Defendant(s) unlawfully ousting or excluding Plaintiff from the premises. Minn. Stat. §§ 504B.231 (formerly § 504.255), 557.08, 557.09.

                        f.         □          $ __________ (3 times $ __________) for Defendant(s) renting condemned property. Minn. Stat. § 504B.204, (formerly § 504.245).

                        g.         □          $ 250.00 or __________ for Defendant(s) violating my right to call for police or emergency assistance. Minn. Stat. § 504B.205, (formerly § 504.215).

            11.       □          Judgment for Plaintiff(s) in the amount of $ __________.

            12.       □          Reasonable attorney fees:

                        a.         □          Up to $500.00. Minn. Stat. § 504B.425 (formerly § 566.25).

                        b.         □          Additional fees:

                                    I.         □          Defendant(s) unlawfully ousted or excluded Plaintiff(s) from the premises. Minn. Stat. § 504B.231 (formerly § 504.255.

                                    ii.        □          Defendant(s) unlawfully terminated utility service. Minn. Stat. § 504B.221 (formerly § 504.26).

                                    iii.       □          Defendant(s) illegally used a shared meter which does not accurately reflect my utility use. Minn. Stat. § 504B.215 (formerly § 504.185), § 504B.221 (formerly § 504.26).

                                    iv.       □          Defendant(s) rented condemned property. Minn. Stat. § 504B.204 (formerly § 504.245).

                                    v.         □          Defendant(s) violated my right to call for police or emergency assistance. Minn. Stat. § 504B.205 (formerly § 504.215).

                                    vi.       □          Defendant(s) committed consumer fraud, Minn. Stat. §§ 325F.68-325F.70, 8.31, and deceptive trade practices. Minn. Stat. §§ 325D.43-325D.48.

                                    vii.      □          My lease began on or after August 1, 2011, or was renewed on or after August 1, 2012, it provides for attorney fees to Defendant’s or Defendant’s attorneys, so I am entitled to attorney fees if I prevail. Minn. Stat. §  504B.172.

            13.       □          Costs and Disbursements:

                        a.         $200.00 under Minn. Stat. § 549.02.

                        b.         The cost of filing a satisfaction of the judgment. Id.

c.Other costs and disbursements (e.g. court filing, service, subpoena, expert, document, and discovery fees). Minn. Stat. § 549.04.

d.If I am allowed to proceed in forma pauperis, order Defendant(s) to pay any fees waived, costs deferred, or expenses paid by the court (e.g., my filing fee) based on my in forma pauperis status directly to the court administrator. Minn. Stat. § 563.01, Subd. 10; HNA Properties v. Moore, 848 N.W.2d 238 (Minn. Ct. App. 2014).

                        e.         Do not award costs and disbursements to Defendant.

            14.       □          Other relief: _________________________________________________.

             15.       Other relief as the Court deems just and proper.

            16.       Certifications

                        a.         Under Minn. R. Civ. P. 11, I certify that, to the best of my knowledge:

                                    i.         this document is not being presented for any improper purpose, such as to harass or to cause unnecessary delay or needless increase in the cost of litigation;

                                    ii.        the claims, defenses, and other legal contentions therein are warranted by existing law or by a non-frivolous argument for the extension, modification, or reversal of existing law or the establishment of new law;

                                    iii.       the allegations and other factual contentions have evidentiary support or, if specifically so identified, are likely to have evidentiary support after a reasonable opportunity for further investigation or discovery;

                                    iv.       the denials of factual contentions are warranted on the evidence or, if specifically so identified, are reasonably based on a lack of information or belief; and

                                    v.         this document does not include any restricted identifiers and that all restricted identifiers have been submitted in a confidential manner as required by Minn. R. Gen. Prac. 11.

I know that I may be fined or sanctioned by the court if this certification is false.

                        b.         Under Minn. Stat. § 358.116, I declare under penalty of perjury that everything I have stated in this document is true and correct.