Fiscal Note Request Worksheet - Minnesota
Fiscal Note WorksheetSection 1-Fiscal Note HeaderBill #:Version:Title:Due Date:Agency Contact (Name and Phone#):Section 2-Fiscal Impact?No Impact (If selected, an explanation is required in the Assumptions section of the narrative.)(The following five fiscal impact questions must be answered before an agency can sign off on a fiscal note.)Fiscal ImpactYesNoState 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”, the Local Government Costs section of the narrative must be completed.)Section 3-Expenditures, Absorbed Costs, Transfer OutDollars (in thousands)FY17FY18FY19FY20FY213.1 Expenditures FundFundFund3.2 Costs Agency Can AbsorbFundFundFund3.3 Transfers OutFundFundFund3.4 Expenditures, Absorbed Costs, Transfer Out (Sum of 3.1, 3.2, 3.3)FundFundFundSection 4 Revenues and Transfers InDollars (in thousands)FY17FY18FY19FY20FY214.1 RevenuesFundFundFund4.2 Transfers InFundFundFund4.3 Revenues and Transfers in (4.1 + 4.2)FundFundFundSection 5 State Cost (Savings) (3.4 – 4.3)Dollars (in thousands)FY17FY18FY19FY20FY21FundFundFundSection 6 Full-Time Equivalent Positions (FTE)Two decimal places allowedFY17FY18FY19FY20FY21Full-Time EquivalentsFundFundFundTotal FTESection 7 – Narrative*Note: Narratives should have a font of Ariel 10 pt.; each text box has a limit of 32,000 characters.*Bill DescriptionAssumptionsExpenditure and/or Revenue FormulaLong-Term Fiscal ConsiderationsLocal Fiscal Impact (Must be completed when Local Fiscal Impact button is “Yes”)References/SourcesI 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.Fiscal Note Coordinator Signature:Date: EBO Comments:I have reviewed this Fiscal Note for reasonableness of content and consistency with MMB’s Fiscal Note policies.EBO Signature:Date: ................
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