IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT IN AND FOR MIAMI-DADE COUNTY, FLORIDA
IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA.
CLAIM OF EXEMPTION
AND REQUEST FOR HEARING
I CLAIM EXEMPTIONS from garnishment under the following categories as
Head of family wages. (You) must check a or b below.
I provide more than one-half of the support for a child or other
dependant and have net earnings of $750.00 or less per week.
I provide more than one-half of the support for a child or other dependant, have net earnings of more
than $750.00 a week, but have not agreed in writing to have my wages garnished.
Social Security benefits.
Supplemental Security Income benefits.
Public assistance (welfare).
Retirement or profit-sharing benefits or pension money.
Life Insurance benefits or cash surrender value of a life insurance policy or proceeds of annuity contract.
Disability income benefits.
Prepaid College Trust Fund or Medical Savings Account.
Other exemptions as provided by law. (explain) _____________________________________________
I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at:
Telephone Number: _______________________________.
The statements made in this request are true to the best of my knowledge and belief.
The foregoing instrument was acknowledged before me this ________ day of ___________________________, 20_____ by
_______________________________ who is personally known to me or who has produced _________________________
as identification and did
/ did not
take an oath.
SWORN TO AND SUBSRCIBED BEFORE ME this ________ day of __________________________________, 20______.
NOTARY PUBLIC, STAMP
CLERK OF COURTS
DEPUTY CLERK / NOTARY PUBLIC
Important - See Reverse
CLK/CT 862 Rev. 03/11
Clerk’s web address: