STATE OF MINNESOTA COUNTY OF __________	DISTRICT COURT  ______________ JUDICIAL DISTRICT _____________ DIVISION: ___________ CASE TYPE: _______________________
____________________________________ ____________________________________,                         Plaintiff, v. ____________________________________ ____________________________________,                         Defendant.	AFFIDAVIT FOR ESCROW OF RENT AND RELATED CLAIMS Poverty Law Form No. REA-1 (August 2025) Case No. ____________________

            ______________________________________________ states upon oath:

            1.         Plaintiff is 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 violations with Plaintiff’s housing under Minn. Stat. § 504B.385, Subd. 1(b):

                        a.         □          On ___________________, the City Inspector ordered the owner(s) and/or manager(s) to repair the property by __________________. Plaintiff has 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 ______________________, Plaintiff sent or gave a written list of violations under Minn. Stat. § 504B.385, Subd. 1(c), as amended by 2025 Minn. Laws Ch. 32, Senate F. No. 2298, Art. 4, § 6, and Minn. Stat. § 504B.001,Subd. 14:

                                    i.         □          Violation(s) of Minn. Stat. Chapter 504B:

________________________________________________________________________________________________________________________________________________

                                    ii.        □          Violation(s) of any federal, state, county, or city laws protecting tenants from discrimination:

________________________________________________________________________________________________________________________________________________

                                    iii.       □          Violation(s) of any applicable tenant rights and landlord obligations for public and subsidized tenancies under local, state, or federal law:

________________________________________________________________________________________________________________________________________________

                                    iv.       □          Violation(s) of an oral or written agreement, lease, or contract for the rental of a dwelling in a building.

________________________________________________________________________________________________________________________________________________

                                    v.         □          The owner(s) and/or manager(s) did not correct the violation(s) within 14 days after Plaintiff sent or gave the list.

            5.         Plaintiff thinks it will cost to $ __________ to repair or correct the violation(s).

            6.         Plaintiff’s monthly rent is $ __________.

                        a.         □          The total rent that Plaintiff has not paid is $ . Plaintiff is paying this amount into court.

                        b.         □          Plaintiff paid all of Plaintiff’s rent to the owner(s) and/or managers.

Optional

            7.         □          The city code requires landlords to have a rental license. Plaintiff’s 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).

            8.         □          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 Plaintiff, Plaintiff’s household members or guests under Minn. Stat. § 609.748: ____________________________________________________________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________________________________________________________

            10.       □          Defendant(s) committed consumer fraud under Minn. Stat. §§ 325F.68- 325F.70, 8.31, Subd. 3(a), and deceptive trade practices under Minn. Stat. §§ 325D.43-325D.48: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            11.       □          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 under Minn. Stat. § 504B.381, Subd. 9:

            1.         □          Repairs:

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

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

                                    i.         □          Plaintiff may complete repairs and/or correct the problems and deduct plaintiff’s 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.         □          Correction of other violations Minn. Stat. Chapter 504B:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            3.         □          Relocation:

                        a.         If Plaintiff must leave while correction of violations are completed or because they are not completed, Defendant(s) shall relocate Plaintiff 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 Plaintiff relocation costs in the amount of $ __________ for _____________________________________________

            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 $500.00 civil penalty payable to Plaintiff for each violation, for a total of $ __________.

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

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

                        b.         □          Ordering the Defendant(s) to have no contact with Plaintiff, Plaintiff’s 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.

            6.         □          Plaintiff shall cease committing consumer fraud under Minn. Stat. §§ 325F.68- 325F.70, 8.31, Subd. 3(a), and deceptive trade practices under Minn. Stat. §§ 325D.43-325D.48. See Love v. Amsler, 441 N.W.2d 555, 557-59 (Minn. Ct. App. 1989).

            7.         □          Rent abatement:

                        a.         □          Retroactive (past) rent abatement:

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

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

                                    iv.       □          For other violations of Minn. Stat. § Chapter 504B, $ _________ per month for the months of ________________________________________________

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

            8.         □          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.         □          $ 500.00 or __________ (3 times $ __________) for Defendant(s) unlawfully terminating utility service. Minn. Stat. § 504B.221.

                        c.         □          $ 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 Plaintiff’s right to call for police or emergency assistance. Minn. Stat. § 504B.205, (formerly § 504.215).

                        h.         □          Up to $1,000 per violation of Plaintiff’s right to organize. Minn. Stat. § 504B.212.

            9.         □          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) rented condemned property. Minn. Stat. § 504B.204 (formerly § 504.245).

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

                                    vi.       □          Defendant(s) committed consumer fraud consumer fraud under Minn. Stat. §§ 325F.68- 325F.70, 8.31, Subd. 3(a), and deceptive trade practices under Minn. Stat. §§ 325D.43-325D.48.

                                    vii.      □          Defendant violated Plaintiff’s right to organize. Minn. Stat. § 504B.212.

                                    viii.     □          Plaintiff’s 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 Plaintiff is entitled to attorney fees if Plaintiff prevails. Minn. Stat. §  504B.172.

            10.       □          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 Plaintiff is allowed to proceed in forma pauperis, order Defendant(s) to pay any fees waived, costs deferred, or expenses paid by the court (e.g.,Plaintiff’s filing fee) based on Plaintiff’s 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.

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

            12.       □          Other relief: _________________________________________________.

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

            14.       Certifications

                        a.         Under Minn. R. Civ. P. 11, Plaintiff certifies that, to the best of Plaintiff’s 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.

Plaintiff knows that Plaintiff may be fined or sanctioned by the court if this certification is false.

                        b.         Under Minn. Stat. § 358.116, Plaintiff declares under penalty of perjury that everything Plaintiff has stated in this document is true and correct.

____________________________________ Date	____________________________________ Tenant/Tenant’s Attorney or Agent
County and State Where Document Is Signed _____________________________________ County _____________________________________ State	____________________________________ ____________________________________ Address ____________________________________ Phone