Form Law 815 - Claim Of Exemption And Request For Hearing Page 2
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2☐8. Retirement or profit sharing benefits or pension money.
☐9. Life insurance benefits or cash surrender value of a life insurance policy or proceeds of annuity
contract.
☐10. Disability income benefits.
☐11. Prepaid College Trust Fund or Medical Savings Account.
☐12. Other exemptions as provided by law (explain) ______________________________________
_________________________________________________________________________________
LAW 815 Rev. 11-15-2012
I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at:
Address: ________________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________
Telephone Number: (_______) ___________________________
The statements made in this request are true to the best of my knowledge and belief.
____________________________________________
______________________________
Defendant’s Signature
Date
STATE OF FLORIDA COUNTY OF SANTA ROSA
Sworn and subscribed to me before me this ________ day of _______________________, 20 _______, by
_______________________________________________
Notary Public/Deputy Clerk
Personally Known ☐ OR Produced identification ☐ Type of Identification Produced __________________
LAW 815 Rev. 11-15-2012
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