Minn. Stat. §§ 491A.02, subd. 9, 550.011
Financial Disclosure Form
The purpose of this Financial Disclosure Form is to tell the JUDGMENT CREDITOR what money and property you have which may be used to pay the judgment the creditor obtained against you in the lawsuit. It also allows you to tell the creditor that some or all of your property and money is "exempt," which means that it cannot be taken to pay the judgment. You must answer all questions on this form. If you need more space, continue your answer on the back of the form or attach additional sheets if necessary. If you have questions about this form, you may contact your local court administrator, call the court self help center at 651-259-3888, or contact an attorney. WARNING: IF YOU CLAIM AN EXEMPTION IN BAD FAITH, OR IF THE JUDGMENT CREDITOR WRONGLY OBJECTS TO AN EXEMPTION IN BAD FAITH, THE COURT MAY ORDER THE PERSON WHO ACTED IN BAD FAITH TO PAY COSTS, ACTUAL DAMAGES, ATTORNEY FEES, AND AN EXTRA $100. 1. JUDGMENT DEBTOR Name 3. Street Address 7. Date of Birth 4. City 8. If Married, Spouse's Full Name 2.
Partnership Other __________
10. Employer or Business 12. Street Address 13. City
9. Home Telephone Number ( ) 11. Work Telephone Number ( ) 14. State 15. Zip 17. How often are you paid? Daily Weekly Other ________ Twice a Month Monthly No If yes, give the source and amount of the income:
16. What are your total wages, salary, or commissions per pay period? $____________________________________ 18. Do you have income from any other source? Yes
19. By answering this question, you will be able to claim the exemptions you have for wages and income. The first exemption is already checked for you, check all others that apply: I claim that 75% of my disposable (after-tax) earnings or 40 times the federal minimum wage (now equals $290 for 40-hour week) is exempt (whichever is greater), unless the judgment is for child support. If the Judgment is for child support, I claim that the following percentage of my after-tax earnings is exempt: 50% (I am supporting a spouse and/or dependent child, and the child support judgment is 12 weeks old or less.) 55% (I am supporting a spouse and/or dependent child, and the child support judgment is more than 12 weeks old.) 60% (I am not supporting a spouse and/or dependent child, and the child support judgment is 12 weeks old or less.) 65% (I am not supporting a spouse and/or dependent child, and the child support judgment is more than 12 weeks old.) I am presently receiving or have received relief based on need in the past 6 months so all my wages are exempt. Type of relief you receive _______________________________________________________________________________ I have been an inmate in a correctional institution within the past 6 months so all my wages are exempt. Name institution and release date _________________________________________________________________________ My income is exempt because it is: Unemployment Comp. Worker's Comp. V.A. Benefits Social Security Accident or Disability Benefits Retirement Benefits Other (Specify)______________ 20. Do you have a checking or savings account? (This includes any account whether you have it by yourself or with someone else, or whether it is in your name or any other name) Yes No For each, provide the following information: Name and address of bank, Credit Union or Financial Institution Type of Account Account Number
21. If you claimed an exemption for your wages or income, you may claim an exemption when your money is deposited in a bank. Claim your exemptions by checking the boxes that apply to you: The money in my account is from exempt wages, income, or benefits. The money in my account is from the exempt sale of my homestead within the past year. The money in my account is from exempt life insurance received on the death of a spouse or parent. The money in my account is from other exempt property (specify) _________________________________________ 22. Do you have any stocks, bonds, securities, certificates of deposit, mutual funds, money market account, etc.? (This includes any whether owned by you alone or with any other person, or whether it is in your name or any other name. If yes, itemize these and the location of each. Yes No
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23. Do you own your home? Yes No Your homestead (house owned and occupied by you) is exempt up to a Value of $300,000 or if used primarily for agricultural purposes, $750,000. Do you own any other houses, land, or real estate? For each, give the following: Yes No Location Estimated Value Amount Owed (if any) To Whom
24. Do you own any motor vehicles, motorcycles, boats, snowmobiles, trailers, etc.? For each, provide the following: Make Model Year Lic. Plate No.
Market Value Amount You Owe (if any)
One motor vehicle worth up to $4,200 (or $42,000 if the vehicle has been modified at a cost of at least $3,150 to accommodate a physical disability making a disabled person eligible for a parking permit under Minn. Stat. § 169.345) after subtracting what you owe is exempt. Which vehicle do you want to claim as exempt?
25. Do you own any of the follow property? Cash or travelers checks Household goods, furnishings, and personal effects that are worth more than $9,450 total Jewelry Coins or stamp collections
Yes No worth more than $13,000 Yes No more than $10,500 total Yes No Inventory
Farm supplies, implements, livestock, grain
Yes No Yes No Yes No Yes No Yes No
Business equipment, tools, machinery worth
Yes No Accounts receivable/claims Yes No not already listed
Are you the owner or partner in any business
Firearms/Guns Life insurance policy with a cash (surrender) value more than $8,400 Any property that you are selling on a contract for deed
Yes No ___________________________________ Yes No Yes No
Amount Owed (if any) To Whom
Any other property (specify)
If you answered yes to any item in question 25, provide the following information: Description and location of property (if not at residence) Estimated Value
If you need additional space to answer the questions, continue your answers here. Indicate the question number you are answering. Attach additional sheets if necessary.
The above information is true and correct to the best of my knowledge. Date: _________________________________ Signature: __________________________________________________ NOTICE: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM TO THE JUDGMENT CREDITOR WITHIN 10 DAYS MAY RESULT IN A CITATION FOR CIVIL CONTEMPT OF COURT.
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