Claim Of Exemption And Request For Hearing Form - Alachua County, Florida
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1IN THE CIRCUIT/ COUNTY COURT OF THE EIGHTH JUDICIAL CIRCUIT
IN AND FOR ALACHUA COUNTY, FLORIDA
________________________________________,
Plaintiff,
vs.
Case No.:
, Div.:
________________________________________,
Defendant,
and
_________________________________________, Garnishee.
CLAIM OF EXEMPTION AND REQUEST FOR HEARING
I claim exemptions from garnishment under the following categories as checked:
__1. Head of family wages. (Check either a. or b. below, if applicable.)
__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.
__9. Life insurance benefits or cash surrender value
of a life insurance policy or proceeds of annuity
__3. Supplemental Security Income benefits.
contract.
__4. Public assistance (welfare).
__10. Disability income benefits.
__5. Worker’s Compensation.
__11. Prepaid College Trust Fund or Medical Savings
__6. Unemployment Compensation.
Account.
__7. Veteran’s benefits.
__12. Other exemptions as provided by law:
__8. Retirement, profit-sharing benefits or pension
________________________________ (explain)
money.
I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at:
Address: _________________________________________________________________________________
Telephone number: ___________________________/ E-mail: ______________________________________
I CERTIFY UNDER OATH AND PENALTY OF PERJURY* that a copy of this Claim of Exemption and Request for
Hearing has been furnished by (check one) __U.S. mail, __hand-delivery, __e-mail e-service, or __e-portal
service on _________________ (insert date), to _________________________________________________
__________________________________________________________ (insert names and address of Plaintiff
or Plaintiff’s attorney and of Garnishee or Garnishee’s attorney to whom this document was furnished).*
I FURTHER CERTIFY* UNDER OATH AND PENALTY OF PERJURY that the statements made in this request are
true to the best of my knowledge and belief.
Date: ____________________________
______________________________________
Defendant's signature
Sworn and subscribed to before me on __________________________________________, by
_______________________________________________ (Name of person making statement)
_______________________________________________
Notary Public/Deputy Clerk
__Personally known OR __Produced identification—type of identification produced: ____________________
*If document is not notarized OR certificate of service not completed, garnishment writ cannot be dissolved by clerk
7/24/14
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