STATE OF MINNESOTA

COUNTY OF	DISTRICT COURT

______________ JUDICIAL DISTRICT

DIVISION:

CASE TYPE:

,

Plaintiff,

v.

,

Defendant.

NOTICE OF REQUEST

FOR JUDGE REVIEW

LASM Form No. JR-1 (August 2004)

Case No.

TO:	, the opposing party:

PLEASE TAKE NOTICE that the undersigned requests a review of the recommended Order and Findings of the Housing Court Referee in this case by a District Court Judge at a time and place set aside for the hearing of such a review by the Court.

1.	This request for review is made upon the following grounds: .

2.	The specific provision(s) of the recommended findings or orders disputed is/are: .

3.	A stay of execution of judgment:

a.	□	is requested. The undersigned proposes payment into court in lieu of bond in the amount of her monthly rent for of $_____, on or before 4:00 p.m. on ___________________________, and $_____ by the ___ day of each month while judge review is pending.

b.	□	is not requested.

4.	Transcript of proceedings.

a.	□	The undersigned requests a transcript of proceedings.

i.	□	The estimated transcript fee must be paid in cash or certified funds to the court reporter in advance with any balance due paid to release of the transcript.

ii.	□	The undersigned requests that the transcript fee by waived in forma pauperis.

b.	□	The undersigned does not request a transcript of proceedings.

5.	Hearing.

a.	□	The undersigned requests a hearing be scheduled before the reviewing judge.

b.	□	The undersigned does not request a hearing.

____________________________________

Date	____________________________________

OPTIONAL VERIFICATION:

Subscribed and sworn to before me

on __________________________

Notary Public