Financial Disclosure FormThe 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 do not understand the questions or don’t know how to fill out the form, call the court administrator for help or consult with 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 ____________________________________
2.•Individual•Partnership •Corporation•Other __________
•Individual•Partnership •Corporation•Other __________3. Street Address ________________________________________________________________________
4. City____________________________________ 5. State ________________6.Zip__________________________
6.Zip__________________________7. Date of Birth ____________________________________
8. If Married, Spouse’s Full Name ____________________________________
9. Home Telephone Number ____________________________________
10. Employer or Business ________________________________________________________________________
11. Work Telephone Number ____________________________________
12. Street Address ________________________________________________________________________
13. City ____________________________________14. State__________________15. Zip ____________________
15. Zip ____________________16. What are your total wages, salary, or commissions per Hour ____________________________________
17. How often are you paid?•Daily•Weekly •Twice a Month•Monthly Other ________
•Daily•Weekly •Twice a Month•Monthly Other ________pay period? $____________________________________
18. Do you have income from any other source?•Yes•No
•Yes•NoIf yes, give the source and amount of the income:
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 $206 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:
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.)
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.)
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.)
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.)
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.
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.
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
My income is exempt because it is: •Unemployment Comp •Worker’s Comp.•V.A. Benefits•Social Security•Accident or Disability Benefits•Retirement 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•NoFor each, provide the following information:
•Yes•NoFor 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 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 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 exempt life insurance received on the death of a spouse or parent.•The money in my account is from other exempt property (specify) _________________________________________
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.
•Yes•NoIf yes, itemize these and the location of each.
Yes•NoIf yes, itemize these and the location of each.________________________________________________________________________________________________________
23. Do you own your home? •Yes•NoYour homestead (house owned and occupied by you) is exempt up to a Value of $200,000 or if used primarily for agricultural purposes, $500,000. Do you own any other houses, land, or real estate? • Yes•NoFor each, give the following:
•Yes•NoYour homestead (house owned and occupied by you) is exempt up to a Value of $200,000 or if used primarily for agricultural purposes, $500,000. Do you own any other houses, land, or real estate? • Yes•NoFor each, give the following: Location Estimated Value Amount Owed (if any) To Whom
____________________________________________________________________________ ____________________
________________________________________ ____________________24. Do you own any motor vehicles, motorcycles, boats, snowmobiles, trailers, etc.?•Yes•No
•Yes•NoFor each, provide the following:
Make ______________________ Model____________________ Year _______ Lic. Plate No.________ Market Value _________
Amount You Owe (if any)______________________
One motor vehicle worth up to $4,000 (or $40,000 if the vehicle has been modified at a cost of at least $3,000 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•Yes•No
•Yes•NoFarm supplies, implements, livestock, grain worth more than $13,000•Yes•No
•Yes•NoHousehold goods, furnishings, and personal effects that are worth more than $9,000 total•Yes•No
•Yes•NoBusiness equipment, tools, machinery worth more than $10,000 total•Yes•No
•Yes•NoJewelry•Yes•No Inventory•Yes•No
•Yes•No Inventory•Yes•NoCoins or stamp collections•Yes•NoAccounts receivable/claims•Yes•No
•Yes•NoAccounts receivable/claims•Yes•NoFirearms/Guns•Yes•No
•Yes•NoAre you the owner or partner in any business not already listed•Yes•No
•Yes•NoLife insurance policy with a cash (surrender) value more than $8,000•Yes•No
•Yes•NoAny other property (specify) ___________________________________•Yes•No
•Yes•NoAny property that you are selling on a contract for deed•Yes•No
•Yes•NoIf you answered yes to any item in question 25, provide the following information:
Description and location of property (if not at residence) Estimated Value Amount Owed (if any) To Whom
_________________________________________________________________________________ ______________
_____________________________________ ______________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.
