Free STATE OF MINNESOTA - Minnesota

State of Minnesota
County
Select County

District Court
Judicial District: Court File Number: Case Type: Housing

Name of Plaintiff(s)/Tenant(s)

vs.

Petition for Emergency Relief Under Tenant Remedies Act (Minn. Stat. § 504B.381)

Name of Defendant(s)/Building Owner(s)

STATE OF MINESOTA COUNTY OF
(County where Affidavit signed)

) ) ss )

My name is , I understand that I am under oath 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 State Zip Code

City/St./Zip:
City

County: Phone: 2. The name, address, and phone number for the owner(s) of the property are: Name: Address:
Street Address Apt. No. City State Zip Code

Phone: 3. The name, address, and phone number for the manager(s) of the property (if different from the owner) are: Name: Address:
Street Address Apt. No. City State Zip Code

Phone:

HOU602

State

ENG

Rev 2/05-D

www.courts.state.mn.us/forms

Page 1 of 4

4.

I am requesting emergency relief from the court because of a loss of one or more of the following utilities, facilities, or other essential services that the building owner and manager are responsible for providing (check all that apply): heat hot water sanitary facilities running water electricity other

5.

The following facts show that I have an emergency caused by the loss of utilities, facilities, or other essential services that the building owner and manager are responsible for providing
(tell the court what the emergency is and why the owner and manager are responsible for providing that utility or service):

________________________________________________________________________

6.

On the following date: ________________, I reported this emergency to:

I have taken the following actions to report this emergency (tell the court HOW you told or tried to tell the building
owner or manager about the problem and WHAT you told the person about the problem):

7. 8.

The building owner or manager did not fix the emergency problem. On the following date _______________ I gave who is the owner and/or manager a twenty four hour notice that I would be requesting emergency relief from the Court today by (tell the court HOW you told or tried to tell the building owner or manager that you were going to court and what you told the person if you talked to the person or left a message): ________________________________________________________________________

HOU602

State

ENG

Rev 2/05-D

www.courts.state.mn.us/forms

Page 2 of 4

9.

This emergency problem is not the result of a deliberate or negligent act or omission by me or anyone acting under my direction or control. (Check box if this applies)

10.

The following other information would be helpful to the Court in granting emergency relief
the court any other information regarding this emergency that you think will be helpful to the court in granting your request for help):

(tell

________________________________________________________________________ ________________________________________________________________________ 11. I am asking the Court to order one or more of the following: Direct the building owner or manager to immediately fix the emergency problems with my housing. Allow me to fix the emergency problems with my housing and deduct the costs from my rent. Direct that an administrator take over operation of the property to complete the emergency problems with my housing. Direct the building owner to pay me a rent refund or credit for the month(s) of when my housing was not fixed. Direct the building owner to give me a rent reduction until the emergency problems are fixed. Directing the building owner to pay a fine if this Order is violated. Directing the building owner to pay reasonable attorney fees. To grant other relief deemed just and proper by the Court:

Verification and Acknowledgements

a.

b.

c.

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. 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. 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.
State ENG Rev 2/05-D www.courts.state.mn.us/forms Page 3 of 4

HOU602

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 of 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 day of , . Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator

Attorney Signature Block Dated:
Signature

Name: Attorney Lic. #: Street Address: City/State/Zip: Telephone:

HOU602

State

ENG

Rev 2/05-D

www.courts.state.mn.us/forms

Page 4 of 4