Case Number: _______________________________________ Judge: ___________________________________
____________________________________ vs _______________________________________________
CLAIM OF EXEMPTION AND REQUEST FOR HEARING
I claim exemptions from garnishment under the following categories as checked:
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 dependent
and have net earnings of $750 or less per week.
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.
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 provide by law.
I request a hearing to decide the validity of my claim.
Notice of the hearing should be given to
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.
STATE OF FLORIDA
COUNTY OF VOLUSIA
Personally Known_________ or Produced identification _____
Identification produced __________________________________________.
Diane M. Matousek
My commission expires:
Clerk of the Circuit Court