Form Cl-0686-1109 - Claim Of Exemption And Request For Hearing - Volusia County, Florida
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1Case Number: _______________________________________ Judge: ___________________________________
Case Style:
____________________________________ vs _______________________________________________
CLAIM OF EXEMPTION AND REQUEST FOR HEARING
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 dependent
and have net earnings of $750 or less per week.
_____
b.
I provide more than one-half of the support for a child or other dependent,
have net earnings of more than $750 per 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.
Veterans’ 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 provide by law.
I request a hearing to decide the validity of my claim.
Notice of the hearing should be given to
me at:
Address:
_____________________________________________________________
_____________________________________________________________
Tel. No.
_____________________________________________________________
The statements made in this request are true to the best of my knowledge and belief. A copy
of this paper has been mailed/hand delivered to the plaintiff or plaintiff’s attorney this date.
Date: _______________________
________________________________
Defendant’s signature
STATE OF FLORIDA
COUNTY OF VOLUSIA
Sworn
and
subscribed
to
before
me
this
_________
day
of
__________________________,
20_______,
by
______________________________________________ .
Personally Known_________ or Produced identification _____
Type of
Identification produced __________________________________________.
Notary Information
Diane M. Matousek
My commission expires:
Clerk of the Circuit Court
______________________________
Notary signature
(seal)
By:______________________________
Print Name
Deputy Clerk
CL-0686-1109
FS 77.041
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