Form Clk/ct 862 - Claim Of Exemption And Request For Hearing Form 2011
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2IN 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.
DIVISION
CASE NUMBER
CLAIM OF EXEMPTION
CIVIL
AND REQUEST FOR HEARING
OTHER
(AFEG)
PLAINTIFF(S)
VS. DEFENDANT(S)
CLOCK IN
I CLAIM EXEMPTIONS from garnishment under the following categories as
checked:
1.
Head of family wages. (You) must check a or b below.
a.
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.
b.
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.
2.
Social Security benefits.
3.
Supplemental Security Income benefits.
4.
Public assistance (welfare).
5.
Workers’ Compensation.
6.
Unemployment Compensation.
7.
Veteran’s benefits.
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) _____________________________________________
___________________________________________________________________________________
I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at:
Address: _________________________________________________________________________________________.
Telephone Number: _______________________________.
The statements made in this request are true to the best of my knowledge and belief.
_______________________________________
___________________________
Defendant’s Signature
Date
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
HARVEY RUVIN
CLERK OF COURTS
BY: __________________________________
(COURT SEAL)
DEPUTY CLERK / NOTARY PUBLIC
Important - See Reverse
CLK/CT 862 Rev. 03/11
Clerk’s web address:
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