Ucf-22 Financial Disclosure Form Page 2

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23. Do you own your home?
Your homestead (house owned and occupied by you) is exempt up to a
Yes
No
Value of $390,000 or if used primarily for agricultural purposes, $975,000. 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.?
Yes
No
For each, provide the following:
Make
Model
Year
Lic. Plate No.
Market Value
Amount You Owe (if any)
One motor vehicle worth up to $4,600 (or $46,000 if the vehicle has been modified at a cost of at least $3,450 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?
Farm supplies, implements, livestock, grain
Cash or travelers checks
Yes
No
worth more than $13,000
Yes
No
Household goods, furnishings, and personal
effects that are worth more than $10,350
Business equipment, tools, machinery worth
total
Yes
No
more than $11,500 total
Yes
No
Jewelry
Yes
No
Inventory
Yes
No
Coins or stamp collections
Yes
No
Accounts receivable/claims
Yes
No
Are you the owner or partner in any business
Firearms/Guns
Yes
No
not already listed
Yes
No
Life insurance policy with a cash
Any other property (specify)
(surrender) value more than $9,200
Yes
No
___________________________________
Yes
No
Any property that you are selling on a
contract for deed
Yes
No
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
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.
JGM301
State
ENG
Rev 7/12
Page 2 of 2

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