FISCAL NOTE WORKSHEET

Additional copies of this fiscal note worksheet (https://www.lbo.mn.gov/fn/documentation/lbofnworksheet.dotx) are available on the LBO website (https://www.lbo.mn.gov/fn/training.html).
To prepare your fiscal note estimate, please use these reference documents available on our website:
•	Fiscal Note Uniform Standards and Procedures
(https://www.lbo.mn.gov/fn/documentation/LBOUSP.pdf)
•	Fiscal Note User Guide
(https://www.lbo.mn.gov/fn/documentation/LBOFNTSUserGuide.pdf)
•	Fund Directory
(https://lbo.mn.gov/fundlist.html)
(Links to the references listed above are also available on the FNTS menu under “Help.”

NOTE: If this fiscal note is classified under Min. Stat. §13.64 Subd. 3(b), its existence and contents remain classified as nonpublic data until the conditions outlined in the statute have been met to make it public data.

Section 1-Fiscal Note Header

Bill #: 
	Version: 
	Title: 
	Date due to Legislature: 
	
Agency Contact (Name and Phone#):

Section 2-Fiscal Impact
☐No Impact (If selected, explain in the Assumptions section of the narrative.)

(Mark your answer for each question in the section below.)
Fiscal Impact	Yes	No	
State Expenditures – Does this bill have an impact on your agency’s spending?			
Fee/Dept. Earnings – Does this bill impact an agency fee or dept. earning?			
Tax Revenue – Does this bill impact state tax revenues?			
Information Technology – Does this bill impact your agency’s information technology systems?			
Local – Does this bill have a fiscal impact on a local government body? 
(Note: if “Yes”, complete the Local Government Costs section of the narrative.)			

Section 3-Expenditures, Absorbed Costs, Transfers Out
Dollars (in thousands)	2025	2026	2027	2028	2029	
3.1 Expenditures						
Fund						
Fund						
Fund						
3.2 Costs Agency Can Absorb						
Fund						
Fund						
Fund						
3.3 Transfers Out						
Fund						
Fund						
Fund						

Sum of Expenditures, Absorbed Costs, Transfers Out (This will be calculated automatically in FNTS)
		
Fund						
Fund						
Fund						

Section 4-Revenues, Transfers In
Dollars (in thousands)	2025	2026	2027	2028	2029	
4.1 Revenues
Fund						
Fund						
Fund						
4.2 Transfers In						
Fund						
Fund						
Fund						

Sum of Revenues, Transfers In (This will be automatically calculated in FNTS)
Dollars (in thousands)	2025	2026	2027	2028	2029	
Fund						
Fund						
Fund						
Section 5 State Cost (Savings) (Subtract Sum of Revenues and Transfers In from Sum of Expenditures, Absorbed Costs and Transfers Out --This will be automatically calculated in FNTS) 
Dollars (in thousands)	2025	2026	2027	2028	2029	
Fund						
Fund						
Fund						

Section 6 Full-Time Equivalent Positions (FTE)
Two decimal places allowed	2025	2026	2027	2028	2029	
Full-Time Equivalents						
Fund						
Fund						
Fund						
Total FTE						

Section 7 – Narrative
Use Arial 9 pt for text in the narrative section.
Use Arial 7.5 pt for tables in the narrative section.

Bill Description

Assumptions

Expenditure and/or Revenue Formula

Long-Term Fiscal Considerations

Local Fiscal Impact (Must be completed when Local Fiscal Impact button is “Yes”)

References/Sources

I have reviewed the content of this fiscal note and believe it is a reasonable estimate of the expenditures and revenues associated with this proposed legislation.

If Information Technology costs are included, my agency’s Chief Information Officer has reviewed the estimate.

Fiscal Note Coordinator Signature:	Date: